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Medical aid

Medical aid, gap cover and health insurance

A medical scheme, a gap policy and a health-insurance policy are three products. A lower premium does not make them equivalent.

Reviewed 29 October 2026 by the WiT Money editorial team. This is general information, not a recommendation from a named adviser.

Key points

  • Only a scheme registered under the Medical Schemes Act is medical aid.
  • Gap cover does not pay every shortfall and does not replace the contribution.
  • Health insurance does not provide prescribed minimum benefits.

Medical aid, in ordinary speech, means membership of a medical scheme supervised by the Council for Medical Schemes. The scheme's rules, not the administrator's advert, decide the benefits. The administrator runs the cards. It is not the scheme.

Gap cover is short-term insurance. It responds to specified shortfalls, often only after the scheme has paid something. A specialist who charges more than the scheme tariff can leave a gap. The gap policy may pay part of it, up to its own limit, or it may not. Health insurance pays the capped benefits in its policy. It is not a scheme and it does not automatically include prescribed minimum benefits.

An illustration of a shortfall

A specialist charges R8 000. The scheme pays its tariff of R5 000. The R3 000 difference is yours unless a gap policy on that event pays some of it. The illustration is not a claim. Co-payments, networks and exclusions still apply.

Open and restricted schemes

An open scheme can take members from the public, subject to its rules, waiting periods and late-joiner penalties. A restricted scheme is only for a defined group, such as an employer. Profmed is treated on this site as a restricted scheme because its published membership rules limit who can join. Do not assume every scheme with a professional image is restricted.

Hospital plans and savings

A hospital option is aimed at in-hospital events and prescribed minimum benefits. It is a weak match for someone who expected every GP visit to be paid. A medical savings account is a portion of your own contribution. When it is empty, day-to-day claims are yours until any threshold benefit in the rules begins.

Questions readers ask

Can I use health insurance instead of a scheme?

They are not substitutes. If you want prescribed minimum benefits, you are looking at a medical scheme. Health insurance does not become one because the premium is lower.

Related

Sources

Page updated 29 October 2026. A source date is the day WiT Money checked that page, not a promise the institution has not changed it since.