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Medical aid glossary

Gap cover

A separate short-term insurance product, not a medical scheme benefit, that covers the shortfall between what a provider charges in hospital and what your scheme pays. Gap cover is regulated as insurance and has its own limits, waiting periods and exclusions.

Where you will see this term

Terms like this appear on claims statements, remittance advices, authorisation letters and scheme rules. Understanding the exact wording your scheme used is usually the first step in working out whether a rejected or short-paid claim can be disputed.

Browse the full glossary.

Related terms

Above Threshold Benefit (ATB)Annual limitAuthority to actBeneficiaryBenefit yearCase managerChronic Disease List (CDL)Chronic medication list (formulary)Chronic registrationClaims shortfallClaims statementClinical motivation

Claim review

Not sure what your scheme's wording means for your claim?

Send us the rejection letter, the itemised account and the clinical notes. We translate the scheme's reasoning into plain English and tell you whether the decision stands up against its own rules and the Prescribed Minimum Benefit regulations.

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This page is provided for general information and does not constitute legal or medical advice. Medical scheme rules, benefit structures and regulations change over time — always confirm the position with your scheme’s current member material, your treating practitioner, or an attorney admitted in South Africa.

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ClaimIQ is a product of Landlodz (Pty) Ltd (Reg. No. 2024/615543/07).
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ClaimIQ SA is an independent medical aid claim review and dispute service. We are not a medical scheme, a broker or a financial services provider.