22 May 2026 – FANews
Many South Africans assume that having medical aid means that the full cost of private healthcare will be covered.
This is often not the case. Patients are increasingly faced with co-payments, specialist shortfalls and sub-limits that leave them responsible for part of the bill. Gap cover plays an important role in addressing these shortfalls, but it is often misunderstood. Misconceptions about how it works, what it covers and who needs it can result in significant out-of-pocket shortfalls when undergoing necessary medical treatment. Understanding these misconceptions is key to avoiding unexpected out-of-pocket medical costs that can have significant consequences for your financial health and wellbeing.
Misconception 1: I have medical aid, so everything is covered
One of the most common assumptions is that medical aid on its own is enough. However, medical schemes pay according to their own scheme rates, while specialists often charge significantly more. This creates shortfalls that must be paid out of pocket. Co-payments and sub-limits are also becoming more common, even on higher-tier plans. This means that members are increasingly responsible for part of the cost of treatment, despite having what appears to be comprehensive medical aid.
Misconception 2: Gap cover is only for certain people or plans
Gap cover is often seen as something only needed on lower-tier medical aid options or only for older individuals. In reality, shortfalls can affect anyone, regardless of age or medical aid plan. Medical events are unpredictable, and many conditions require multiple procedures and follow-up treatment. Recent Turnberry claims data shows that individual shortfalls can exceed R200,000 for conditions including cancer, cardiac events and spinal procedures. These are not isolated incidents, and as risk is not limited to a specific condition or age group, gap cover is essential in protecting against large, unanticipated expenses.
Misconception 3: Gap cover is expensive and not worth the cost
Some may assume that gap cover is expensive, but the monthly premium is low compared to the cost of a single medical shortfall. Premiums are typically a few hundred Rand per month, and the value of cover far exceeds this. Aside from high-cost single incidents, there are also many medical conditions that lead to multiple claims over time. Turnberry data shows numerous clients who have claimed between R406,000 and R678,000 in shortfalls over periods of between four and nine years. Even in less extreme cases, the cost of not having gap cover is far higher than the cost of the premiums.
Misconception 4: Gap cover must match your medical aid membership
There is often confusion around how gap cover is structured. Some assume that each individual needs a separate policy or that family members must be on the same medical aid. In many cases, one gap cover policy can cover a family, including a spouse and children. The policyholder does not need to be the main member on the medical aid, and spouses can also be on different medical aid plans. Each person on the policy also has their own Overall Annual Limit for cover, rather than sharing a single limit.
Misconception 5: Gap cover will pay everything
Gap cover does not replace medical aid and does not cover every possible expense. It works alongside medical aid by covering shortfalls, co-payments and sub-limits. It also cannot pay for treatments that are not covered by medical aid at all. This is why it is important that gap cover is aligned with your specific medical aid option.
Understanding your cover before you need it
These misconceptions often lead to people not taking out gap cover at all, or taking out cover that does not match their medical aid or individual needs. In both cases, the result is the same: exposure to out-of-pocket expenses that could have been avoided.
Without gap cover, the cost of medical expense shortfalls, co-payments and sub-limits can be significant, particularly where multiple procedures or ongoing treatment are required.
Gap cover helps to reduce this exposure by covering the shortfalls that medical aid does not fully pay. In many cases, a single claim can exceed the total premiums paid over several years, which highlights the financial impact it is designed to protect against. However, for it to be effective, your gap cover must be structured correctly and aligned to your medical aid option.
Speak to your broker or financial advisor to ensure that your medical aid and gap cover work together, and that your cover is aligned to your needs, your medical aid option and your level of risk.
Brian Harris, General Manager: Operations at Turnberry Management Risk Solutions
Five common misconceptions about gap cover that cost South Africans thousands
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Turnberry have been absolutely amazing. Mitze was the consultant on our claim and she went above and beyond to assist us. The first claim was submitted online, thereafter when I tried to submit the form for another claim, the online form was not available. However, all claims were emailed to Mitze who ensured they were processed. If you want exceptional service and a hassel free claim process, use Turnberry.
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BEST INSURANCE PRODUCT I HAVE EVER PURCHASED. Have claimed numerous times and always been paid in full in a short space of time. No drama or fuss of insurer looking for reasons not to pay. I have already recommended Turnberry Gap Cover to my family, friends and colleagues, and will continue to do so. Happy to have my name used for a product that I highly recommend. Fran Davidson