Key Reasons why Gap Cover is important
- Albert Johnson
- 1 hour ago
- 3 min read
Even with a comprehensive medical aid, many South Africans are shocked to discover that doctors, anesthetists, and specialists often charge far more than what medical schemes will pay.
This creates a medical expense shortfall, a “gap” that you must pay out of pocket.
Gap Cover bridges this gap, protecting you and your family from high, unexpected medical bills. Wallstreet Financial Services works with Zest Life and they have just published their benefit and premium guides for 2026. Lets unpack it.
The Problem
Medical schemes usually pay hospital and specialist costs up to a specific tariff rate.
However, many procedures cost far more than that.
Here are some examples of real shortfalls Zestlife covered in 2024/2025:
Caesarean Section: R47 535
Knee Replacement: R98 173
Hip Replacement: R205 490
Breast Cancer Surgery: R132 442
Spinal Surgery: R227 263
Without Gap Cover, these amounts could come directly from your savings.
The Solution
Gap Cover is a health insurance policy that covers these shortfalls when your medical aid doesn’t pay the full amount. It’s designed for medical scheme members and is not a substitute for medical aid — rather, it enhances your existing cover.
Zestlife offers three plans to suit different needs and budgets,, which can be added with ANY medical aid and option:
Universal Gap Cover – most comprehensive (up to 500% of medical scheme tariff)
Essential Gap Cover – affordable protection for common shortfalls
Optimal Gap Cover – tailored for individuals under 35
Key Benefits of Gap Cover
1. Covers In-Hospital Shortfalls
Protects you from in-hospital doctor and specialist fees that exceed your medical scheme tariff — up to 500% of the scheme rate.
2. Out-of-Hospital Cover
Includes over 60 outpatient procedures (such as CT, PET and MRI scans, chemotherapy, and radiotherapy) with cover up to 500% of the scheme tariff.
3. Co-Payment Protection
Covers co-payments imposed by medical schemes for:
Hospital admissions
Specialist scans (CT, MRI, PET)
Selected medical procedures(Penalty co-payments are excluded)
4. Cancer and Oncology Benefits
Oncology Co-payment cover once medical aid limits are reached
Cancer Assist Benefit (up to R20 000) for first-time diagnosis
Optional Extended Cancer Cover of R132 000 or R264 000
Cover for cosmetic breast reconstruction after mastectomy
5. Emergency & Accidental Cover
Casualty treatment after accidents (up to R26 700 per year)
Emergency cover for children under 11
Accidental tooth fracture cover (up to R27 000)
Accidental death and disability cover (R55 000 + violent crime assist)
6. Internal Prosthesis and Robotic Surgery Cover
Covers shortfalls for hip/knee replacements, pacemakers, stents, and spinal fusion devices, up to R46 000 per year. Includes robotic medical procedure shortfalls (up to R39 500 per year).
7. Additional Peace of Mind Benefits
Trauma and bereavement counselling (up to R32 000)
Medical aid premium waiver after accidental death or disability
International travel benefit for accidents or illness abroad
Here are some key insights from Zest Life and the 2026 Gap Cover pricing and benefits.
Why You Shouldn’t Go Without Gap Cover
Medical specialists in South Africa can charge 300%–500% more than medical aid rates.
A single major operation could leave you with a six-figure bill.
Gap Cover ensures financial protection, peace of mind, and continuity of care when you need it most.