This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme.
This Policy is not a substitute for Medical Scheme membership.
What is Gap Cover?
Gap Cover is a short term insurance product that helps you cover certain cost shortfalls that your medical aid does not cover. These medical shortfalls occur when your selected doctor or medical specialist charges rates that are more than what your medical aid will pay for. These shortfalls vary according to the fees charged by a medical specialist and the nature of the procedure required.
Kaelo Gap Cover provides security regardless of the medical aid plan or option selected. This freedom allows patients to select the very best doctors without having to worry about whether the medical bills will be fully covered by the medical aid.
Why Gap Cover is essential:
Gap Cover is essential due to the high cost of specialist treatments and above-inflation increases, meaning that more people are at risk of being left behind and excluded from the quality medical care they need and deserve.
Many medical disciplines are increasing their charges at a rate much higher than that of inflation, some up to 500% of medical aid rates. Patients and their families are required to meet the cost shortfalls that exist between what their medical aid covers and the actual charge of the specialist.
Kaelo Gap Cover Benefits:
Core Benefits:
- Tariff Shortfalls
- Co-Payments and Deductibles
- Shortfalls from Sub-Limits
- Oncology Tariff Shortfalls
- Oncology Sub Limits
- Oncology Co-Payments
- Oncology First-Time Diagnosis
- Out-of-Hospital Tariff Shortfalls
- Penalty Co-Payment
- Innovative Oncology Medicines
- Dental Reconstruction Benefit
Benefit Extenders:
- Family Booster
- Casualty Child Illness
- Casualty Emergency
- Accidental Casualty
- Hospital Booster
- Family Protector
- Medical Scheme Contribution Waiver
- Gap Premium Waiver
- Road Accident Fund Claims
Lifestyle Benefits:
Brochures:
2026 Kaelo Gap Cover Comparisons
2026 Kaelo Optima Gap Cover Brochure
2026 Kaelo Core Gap Cover Brochure
2026 Lifestyle Benefits Brochure
Resources:
Frequently Asked Questions
General
Dependants can be included in your policy if you apply for their cover and they meet the eligibility criteria for a dependant as noted in the policy.
Can shortfalls occur in any other way?
Yes, they can also occur if your medical scheme imposes co-payments or deductibles on certain procedures, e.g. MRI/CT scans or diagnostic scopes while in hospital.
Do all specialists charge more than the medical aid tariff?
A lot of them do and the charges vary from 1.5 times above what the medical scheme covers up to as much as 5 times more than the medical aid tariff.
Private Doctors (GPs)
A dispensing provider may issue a script if they recommend medicine that is not kept in their rooms. These medicines are usually a higher schedule medicine and will not be covered. Please note that if your Healthcare Provider is a dispensing Doctor (GP), they are paid for services that include the consultation and prescribed medicine on the approved Prime Cure Formulary (medicine list). Go to this link to see the approved formulary: https://www.primecure.co.za/medicine-management/
Can I go to any Doctor (GP), dentist or optometrist?
You need to go to a Prime Cure Network Healthcare Provider (GP, dentist etc) to avoid any unnecessary out-of-pocket payments. However, if you are on the MyHealth Plus plan, you have one visit to a non-Prime Cure Network Doctor (GP) per Insured Party Per Annum, with a limit of two non-Prime Cure Network visits per Family Per Annum. You are required to get authorisation before you visit a non-Prime Cure Network Doctor, and out-of-network visits are limited to one visit Per Insured Party Per Annum, and up to two per Family Per Annum. You are required to get authorisation before you visit a non-Prime Cure Network Doctor, and out-of-network visits are limited to one visit Per Insured Party Per Annum, and up to two per Family Per Annum. Consultations are paid up to a limit of R1 100 per visit.
Kaelo Gap is not a Medical Scheme or an Insurer.
The administrator for Kaelo Gap is Kaelo Risk (Pty) Ltd, an authorised Financial Services Provider (FSP 36931).
Kaelo Gap is insured by Centriq Insurance Company Limited (“Centriq”), a licensed non-life insurer and an authorised Financial Services Provider (FSP 3417).
Kaelo Risk (Pty) Ltd holds preference shares in Centriq Insurance Company Limited.
Lifestyle Benefits are Kaelo offerings. Service Providers are contracted to Kaelo.