Monthly premium
By age band, as Zestlife publishes it. 2027 premiums take effect on 1 January 2027.
| Age | 2026 | 2027 | Change |
|---|---|---|---|
| Just you, under 42 | R276 | R293 | +6.2% |
| Family, everyone under 42 | R495 | R495 | +0.0% |
What it covers
What it pays
Limits and joining
Who is covered
In Zestlife’s own words.
- Zestlife Gap Cover is available to individuals and families on all South African medical schemes. Optimal Gap Cover is available to families and single individuals younger than 42. Individual Cover is for those who don’t have any medical scheme dependants. Family Cover is for the main medical scheme member, spouse and family dependants including adult dependants, on the same medical scheme. Family cover also extends to a policyholder’s spouse and mutual children that are registered as dependents on the spouse’s medical scheme. Zestlife Zestlife Gap Cover brochure 2027, p3
What each benefit means
In Zestlife’s own words, with its examples of when it pays and when it doesn’t.
In-hospital
Cover for shortfalls on doctors and specialist charges that exceed the medical scheme tariff amount. The shortfall covered is the difference between the total costs charged by medical practitioners and the amount payable or paid by your Medical Scheme. This benefit covers in-hospital doctor and specialist shortfalls for a wide range of surgeries, treatments and procedures that may be required. Including in-hospital dental procedures and treatment for cancer.
Zestlife Zestlife Gap Cover brochure 2027, p3
Out-of-hospital
Cover for shortfalls on 60 out-patient procedures including CT, PET and MRI scans. The shortfall covered is the difference between the total costs charged by medical practitioners and the amount payable or paid by your medical scheme. This benefit covers doctor and specialist shortfalls for 60 treatments and procedures that may be required. This includes chemotherapy and radiotherapy for treatment for cancer.
Zestlife Zestlife Gap Cover brochure 2027, p3
General Co-payments
Cover for co-payments imposed by medical schemes for hospital admissions, CT, PET and MRI scans and specified medical procedures. This benefit is intended to cover co-payments imposed by medical schemes for in-hospital treatment and on the 60 out-of-hospital procedures we cover. Dentistry (in-hospital) and cancer treatment (not medicine) co-payments are covered. Penalty co-payments charged by medical schemes are not covered. No cover is provided for the penalties imposed e.g. not obtaining a general practitioner referral prior to consulting with a specialist; not obtaining a pre-authorisation prior to a procedure; not following assessment criteria of medical scheme back and neck program prior to undergoing spinal surgery.
Zestlife Zestlife Gap Cover brochure 2027, p4
Non-network Co-payments
Cover for co-payments charged by medical scheme when treated in a non-network hospital or by a non-network medical practitioner. This cover provides for two claims with a maximum of R16 800 per claim per policy per calendar year.
Zestlife Zestlife Gap Cover brochure 2027, p4
MRI, PET and CT Scans and Scopes in Excess of Medical Scheme Sub-limit
Cover in part or in full for MRI, PET and CT scans and scopes when the medical scheme sub-limit has been reached. Cover is provided up to a maximum amount of R5 200 per individual claim up to a maximum of R16 800 per policy per calendar year. This benefit cannot be claimed along with a co-payment cover claim.
Zestlife Zestlife Gap Cover brochure 2027, p5
Casualty Facility Treatment for Injury in an Accident
Cover for treatment in a hospital casualty facility or by a GP where there is no registered hospital casualty facility within 30km radius, within 48 hours following accidental injury. Cover is for the facility fee, medical practitioner consultation, on site medication, ward stock, radiology and pathology, as not covered by the medical scheme. Cover is provided up to a maximum amount of R28 000 per policy per calendar year. This benefit does not cover casualty facility treatment for disease or illness, prescribed medicines for use after leaving the casualty facility, follow-up treatment, fees charged for the fitment and cost of prosthesis and devices such as crutches, limb guards, splints and braces.
Zestlife Zestlife Gap Cover brochure 2027, p5
Internal Prosthesis and Artificial Joints
Cover for medical expense shortfalls and co-payments on internal prosthesis (including artificial joints). An internal prosthesis is a device that is placed inside a person’s body during a procedure to permanently replace a body part or to improve a lost or reduced bodily function. Examples of internal prosthesis include artificial hip and knee joints and the implanted devices in spinal fusion. This benefit covers the shortfall not covered in full by the medical scheme due to the annual limit being exceeded. It also covers co-payments charged by medical schemes. Cover is provided up to a maximum amount of R48 300 per policy per calendar year. This benefit does not apply where the insured is on a medical scheme option that does not include internal prosthesis cover. Breast implants, cochlear implants and neurostimulators are not covered. Stents are covered up to a maximum shortfall amount of R5 300 for each individual insured under the policy per calendar year.
Zestlife Zestlife Gap Cover brochure 2027, p6
Accidental Dentistry Cover
This benefit provides cover for up to R28 400 for accidental tooth fracture. This benefit is payable at a rate of R4 100 per fractured tooth irrespective of medical scheme contribution to treatment cost. Tooth fracture is defined under this benefit as being the loss of 50% or more of the visible portion of a tooth and where the dental nerve is permanently damaged. The benefit covers accidental tooth fracture to permanent teeth (crowns and implants are excluded) due to an external injury to the mouth. Treatment must take place within 10 days of the accidental tooth fracture event.
Zestlife Zestlife Gap Cover brochure 2027, p7
Accidental Death and Permanent and Total Disability Cover
This benefit provides R55 000 cover for the unexpected costs that may arise in the event of accidental death or accidental permanent and total disability. Accidental death is when an insured individual’s death occurs within 12 months as a direct result of an accident. Accidental permanent and total disability is when an insured individual’s disability occurs due to an accident and have been diagnosed and confirmed within one month of the accident. If an Accidental and Total Disability benefit has been paid, then no further benefit is payable on Accidental Death.
Zestlife Zestlife Gap Cover brochure 2027, p7
Violent Crimes Assist Benefit
This benefit is paid in addition to the Accidental Death and Permanent and Total Disability Cover benefit and provides a once off payment of R55 000 for death or permanent total disability arising from violent crime. Accidental death by violent crime is when the insured individual’s death occurs within 12 months as a direct result of a violent crime. Accidental permanent and total disability is when an insured individual’s disability occurs due to a violent crime that has been diagnosed and confirmed within one month of the accident. This benefit will be capped at legislated limits if the death relates to a minor.
Zestlife Zestlife Gap Cover brochure 2027, p8
Trauma and Bereavement Counseling Cover
This benefit provides cover for the cost of trauma and bereavement counselling required following the insured being the subject or witness of an act of violence or traumatic accident or loss of an immediate family member. This benefit provides up to R1 000 per session with an overall maximum benefit of R33 600 for counselling treatment that commences within 6 months of the traumatic event and is payable for a single treatment period of up to 6 months per policy per calendar year.
Zestlife Zestlife Gap Cover brochure 2027, p8
Medical Scheme and Gap Cover - Premium Waiver Cover
This benefit provides cover for the combined annual (12 months) amount of a policyholder’s medical scheme and gap cover premiums following accidental death or accidental permanent disability of the policyholder. This benefit provides cover of up to R136 500.
Zestlife Zestlife Gap Cover brochure 2027, p8
Extended Cancer Cover
This is an optional policy benefit. If you or any of your dependents insured under the policy are diagnosed with cancer for the first time, we will pay you the Extended Cancer Cover benefit of R136 000 or R272 000 to cover the unexpected costs which may arise as a result of the diagnosis. This covers the policyholder and medical scheme dependants insured under the policy. When applying for this cover, policyholders will be required to answer an underwriting question that relates to previous diagnosis or treatment of cancer. This cover excludes skin cancer and has a 12-month pre-existing condition exclusion and a 6-month upfront waiting period from the date of commencement of cover. Cover continues until the insured’s 65th birthday.
Zestlife Zestlife Gap Cover brochure 2027, p11
Waiting periods
In Zestlife’s own words.
- There are no general or condition-specific waiting periods that withhold cover after commencement. However, the 12-month pre-existing condition exclusion applies to conditions for which medical advice, diagnosis, care or treatment was received or would reasonably have been recommended in the preceding 12 months. Zestlife Zestlife Gap Cover brochure 2027, p9
- Pregnancy existing before the start date is treated as a pre-existing condition and pregnancy/birth-related claims are excluded for 12 months from commencement. Zestlife Zestlife Gap Cover brochure 2027, p9
- This cover excludes skin cancer and has a 12-month pre-existing condition exclusion and a 6-month upfront waiting period from the date of commencement of cover. Zestlife Zestlife Gap Cover brochure 2027, p11
How to claim
In Zestlife’s own words.
Claiming
All claims must be lodged within 180 days of the medical treatment giving rise to the claim. The claim form can be found on www.zestlife.co.za. Claim pay-outs are either made to the policyholder or directly to the treating doctors, specialists or medical service providers, at the insurer’s discretion.
Zestlife Zestlife Gap Cover brochure 2027, p11
What it does not pay for
Zestlife’s exclusions (26)
- Nuclear weapons or nuclear or ionizing radiation.
- Suicide, attempted suicide or intentional self-injury.
- The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a registered medical practitioner (other than the insured person).
- Illness or injury caused by the use of alcohol.
- Illegal behaviour, or as a result of breaking the law of the Republic of South Africa.
- Participation in war, terrorist activity, invasion, rebellion, active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike or the activities of locked out workers.
- All forms of aviation except commercial aviation where you are a fare paying passenger or a pilot or air crew on a commercial flight.
- Participation in any form of race or speed test involving any mechanically propelled vehicle, vessel, craft or aircraft.
- Cosmetic surgery unless required due to illness or injury.
- Penalty co-payments imposed by medical schemes for not following the rules of the medical scheme. An example of this type of penalty co-payment is the amount charged by medical aids for not obtaining pre-authorisation prior to undergoing a medical procedure.
- Medication and other materials including prosthetic products such as crutches, limb guards or braces.
- External prosthesis.
- Cancer treatment or planned procedures received outside the Republic of South Africa.
- Treatment for obesity or treatment that is required as a result of obesity.
- Elective or routine procedures and physical examinations, which are not required because of a specific medical condition that negatively impacts your health or is necessary due to poor health. This includes tests, annual check-ups, ECG’s, scopes, ART (assisted reproduction therapy), elective circumcisions or any other procedure due to family history or illness or medical conditions, etc.
- Treatment for depression, mental or stress-related conditions.
- Claims not covered by the medical scheme.
- Split billing charges. These are medical practitioner and medical service provider charges, charged separately to those submitted to medical scheme.
- Hospital, hospice, step-down facility and Day Clinic costs.
- Day-to-day medical practitioner charges.
- Breast or dental implants.
- Emergency medical transportation.
- Out-of-hospital dental procedures.
- Exploratory procedures or procedures that are paid for by your medical scheme on exception or ex-gratia basis.
- Diagnosis and/or treatment for sleeping disorders.
- Home and private nursing, except as specifically provided for under the First Night Home Recovery Benefit.
Zestlife Zestlife Gap Cover brochure 2027, p10
Words used
As Zestlife defines them.
- Split billing
- split billing is the practice where a medical practitioner charges a medical scheme member an additional fee on top of the medical practitioner’s treatment charge amount submitted to medical scheme. Zestlife FAQs, p4
- Internal prosthesis
- An internal prosthesis is a device that is placed inside a person’s body during a procedure to permanently replace a body part or to improve a lost or reduced bodily function. Zestlife Zestlife Gap Cover brochure 2027, p6
Questions about Optimal Gap Cover
Answered from Zestlife’s brochures.
How much does Optimal Gap Cover cost in 2027?
From 1 January 2027: R293 a month for just you, under 42; R495 a month for family, everyone under 42.
How much is Optimal Gap Cover going up for 2027?
For a family at Just you, under 42, from R276 to R293 a month, +6.2%.
Can I join after 41?
No. New members join between 18 and 41.
Is there a waiting period?
Yes. 0 months general, and 12 months for conditions you had before joining.
Does Optimal Gap Cover cover cancer?
No. Optimal Gap Cover does not include cancer cover.
Which co-payments does it cover?
One co-payment a year that your medical scheme charges.
Is there a limit on what it pays?
Yes. R230 800 per person a year.
Zestlife’s own answers
Quoted from Zestlife’s frequently asked questions (Zestlife FAQs, pp1–4).
What is Gap Cover?
Gap Cover is a solution for the common problem of self-payment shortfalls that medical scheme members face. Gap Cover is not a medical scheme or a substitute for medical scheme membership and the cover is not the same as a medical scheme. It’s a health insurance policy that covers medical expense shortfalls that arise when your medical scheme only covers part of your medical treatment costs.
Are day-to-day general practitioner (GP) consultations covered?
No, day-to-day charges for GP, specialist, optometrist, dentist and other medical practitioner visits are not covered.
What out-of-hospital procedures are covered?
Although Gap Cover has been primarily designed to cover medical expense shortfalls and co-payments arising from in-hospital treatment and procedures, benefits are also payable in the event of shortfalls and/or co-payments arising from certain out-patient treatment and procedures. There are 60 procedures that are frequently performed out-of-hosptial for which shortfalls are covered such as skin grafts, laser eye surgery, grommets and chemotherapy. Please contact us for the full list.
Are pre- and post-surgery consultations covered?
Yes, the shortfalls on fees charged by an admitting medical practitioner for consultation before and after surgery are covered. Cover is provided up to R3 400 for each individual insured under the policy per calendar year. To qualify for cover the consultation must occur within 30 days before or after the surgery. Consultations relating to C-sections and diagnostic procedures such as biopsy’s and scopes (e.g. colonoscopy, gastroscopy and endoscopy etc) are not covered.
Can Gap Cover only be used to cover medical expense shortfalls and co-payments on certain medical schemes?
No, Gap Cover can be taken out to cover individuals and families on any registered South African medical scheme.
Who is covered?
Zestlife Gap Cover is available to individuals and families on all South African medical schemes. Optimal Gap Cover is available to individuals and families where all members are younger than 42. Individual Cover is for those who don’t have any medical scheme dependants. Family Cover is for the main medical scheme member, spouse and family dependants including adult dependents, on the same medical scheme. Family cover also extends to a policyholder’s spouse and mutual children that are registered as dependents on the spouse’s medical scheme.
When will cover commence?
Gap Cover policyholders select the cover commencement date. This can be any date from the 1st day of the month, following the month in which the Gap Cover application occurs. For example when an online, by phone or paper Gap Cover application is completed and submitted on the 25 April, the policyholder can choose a cover commencement of the 1st May or any date thereafter.
Can the Gap Cover commencement date be backdated to the medical scheme cover start date?
No, cover under the policy can only commence on a date after the Gap Cover application is completed and submitted. This can be any date from the 1st day of the month, following the month of the Gap Cover application.
When will premium payments commence?
Gap Cover policyholders select the commencement date of cover and similarly select the day and month for their first premium payment.
Are there any fees or other amounts that will be charged in addition to the Gap Cover monthly premium?
No, there are no policy fees or other additional charges. Any broker fees will need to be approved by the insurer.
When will new policyholders receive their Gap Cover policy documents?
Policy documents are prepared and sent within a week of taking out Gap Cover.
What is required from a policyholder to cancel a Gap Cover policy?
The Gap Cover policy can be cancelled by giving Zestlife 31 calendar days’ written notice. Where policy cancellation takes place within 31 days following the commencement of cover, any premiums paid will be refunded.
Does the gap cover policy have a surrender value?
No, Gap Cover is not a savings or endowment policy and therefore there is no surrender value on a gap cover policy.
Will monthly premiums increase in the future?
Yes, there are two reasons why premiums will increase annually in future. Premiums charged for Gap Cover are likely to increase every year in line with rising medical costs and increasing medical expense shortfalls and co-payments as covered under the policy. The second reason is that Gap Cover is an annually renewable policy with premiums determined by the policyholder’s age, or the eldest insured member in the case of family cover. When an insured person’s age exceeds the Gap Cover age bracket under which they are covered, the policy will be moved to the next age and premium bracket from 1 January the year following. Annual Gap Cover premium increases, benefit enhancements, introduction of new benefits and any changes to policy terms and conditions are communicated to policyholders in advance and are effective from 1 January for the new calendar year.
Do policyholders on Gap Cover’s individual cover (not family cover) options need to notify Zestlife when they require additional medical scheme dependants to be covered by their Gap Cover policy?
Yes, Gap Cover’s individual cover (not family cover) options only provide cover for the policyholder. When a policyholder who is on a Gap Cover individual cover option, has a change in circumstances that requires additional cover for new or existing medical scheme dependents, Zestlife must be notified to assist in changing them to a Gap Cover family cover option.
Do I need to remain on medical scheme to receive the benefits of Gap Cover?
Yes, you are only covered by Gap Cover while you are a member of a registered South African medical scheme.
Who is the Insurer of Gap Cover?
Guardrisk Insurance Company Limited, a licensed non-life insurer and authorised FSP (75).
Is a medical examination required when applying for Gap Cover?
No medical examination is required.
How are claims submitted?
Policyholders can contact Zestlife by email on info@zestlife.co.za or by phone on 0860 009 378 for advice and assistance with the submission of claims. Alternatively the Gap Cover claim form and list of required claim documents are available on Zestlife’s website www.zestlife.co.za/claims/. Please remember that Zestlife must be notified of claims within 6 months of the medical treatment received and the completed claim form and the required support documents must be submitted to Zestlife within 12 months after the medical treatment received.
What documents will be required when making a Gap Cover claim?
A completed Gap Cover claim form, and where applicable a copy of the hospital account, medical practitioner accounts and medical scheme statement detailing the medical scheme contribution towards hospital and medical practitioner charges. When claiming for medical scheme co-payment charges, a copy of the medical scheme pre-authorisation letter and proof of co-payment paid is required.
How long does it take for the settlement of a claim?
Approximately 15 working days from receipt of a completed claim form and all required documentation.
To whom are Gap Cover claim amounts paid?
The claim amount will be paid to the Gap Cover policyholder (in which case the policyholder has the responsibility of settling the accounts with the medical practitioner or service provider) or the claim amount may be paid directly to the medical practitioner or service provider, at the discretion of the insurer. Please note that claim amounts payable directly to the policyholder cannot be paid into a business bank account or into a third party’s bank account.
Can I continue on Optimal Gap Cover if I or one of my medical aid dependants are over 42?
Yes, once you or one of your medical aid dependants turn 42 you are able to continue on the Optimal for families option, with an adjusted premium, until you are 65.
When changing to Zestlife Gap Cover from another gap cover policy how are waiting periods applied to pre-existing health conditions?
Where a policyholder is moving from an existing gap cover policy to Zestlife Gap Cover, waiting periods will only be applied to the unexpired part of the 12 month pre-existing condition waiting period. This is as determined from the commencement date of the existing gap policy and applies to shortfalls and co-payments covered under the existing gap cover policy and Zestlife Gap Cover. A 12 month pre-existing condition waiting period will however apply to any Gap Cover benefit not provided under the existing policy.
What documentation is required to replace an existing gap cover policy as provided by another insurer, with Zestlife Gap Cover?
Along with a completed Zestlife Gap Cover application form and Replacement Policy Advice Record the following documents are required: Copy of current gap policy contract and schedule confirming the policy commencement date and current benefits provided by the policy. Confirmation of the effective date of cancellation of current gap policy. Confirmation of medical aid membership and list of medical scheme dependants.
Does Gap Cover cover corrective jaw surgery also known as orthognathic surgery?
Yes, the shortfall on doctors and specialists in-hospital charges will be covered, provided: The treatment is not subject to the pre-existing condition exclusion within the first 12 months of cover. It is not deemed an elective/ cosmetic procedure by the insured’s medical scheme. The medical scheme covers the treatment from the insured’s Major Medical Benefit (MMB).
Are medical expense shortfalls and co-payments for circumcision covered?
Yes, Gap Cover will cover medical expense shortfall charges and co-payments levied by the medical scheme if the circumcision is medically required due to an underlying health condition. However, routine and ritual circumcision is deemed an elective procedure and is therefore not covered.
Are split billing charges covered by Gap Cover?
No, split billing is the practice where a medical practitioner charges a medical scheme member an additional fee on top of the medical practitioner’s treatment charge amount submitted to medical scheme.
Are home birth medical expense shortfalls covered?
Yes, cover is provided for registered midwife charges in excess of the medical scheme tariff rate or medical scheme contribution to these charges. Please note this benefit does not cover doula charges and is subject to: Medical scheme approval of home birth costs. Gap Cover pre-existing condition exclusion on birth related claims in the first 12 months following the insured’s policy commencement date.
Does Gap Cover apply while outside the borders of South Africa?
Yes, cover applies for the first 90 consecutive days while outside the borders of South Africa. Gap Cover does not cover planned procedures and cancer treatment outside the borders of South Africa.
Are Gap Cover premiums tax deductible?
No, Gap Cover policy premiums are not tax deductible in the same way that your medical scheme contributions are and no IT3 tax certificates can therefore be issued for this purpose.
Are adult dependants covered?
Yes, Gap Cover’s Universal, Essential and Optimal family cover options (not individual cover options) do cover adult dependants that are a parent, child or sibling of the policyholder and registered on their medical scheme as an adult dependant.
Does the policy cover more than one eligible spouse?
No, Gap Cover’s Universal, Essential and Optimal family cover options (not individual cover options) do cover one spouse as registered on the policyholders’ medical scheme. Where the policyholder has more than one spouse the policyholder must inform Zestlife of the spouse that will be covered. This must occur in advance of any spousal Gap Cover claims.
Does Gap Cover have a maximum entry age?
There is no maximum entry age on Gap Cover’s Universal and Essential options. For Optimal Gap Cover the maximum entry age is younger than 42.
Are unmarried partners covered?
Yes, Gap Cover’s family options provide cover for partners who are covered on the policyholders’ medical scheme membership. This cover does not apply to individual cover options.
Factual information from Zestlife’s published brochures. It is not advice. Compiled by Eldon de Waal, CFA, the licensed advisor behind AURA. Catalogue v175, built 2026-10-19.