Expert advice on healthcare, benefits & short-term insurance - talk to us.
Independent advice on medical scheme selection, GAP cover, and actuarial planning – built around what your health needs actually require.
As independent healthcare consultants, 4D Healthcare Consulting has built strong partnerships with a range of medical schemes, health insurance providers, and gap cover providers to meet our clients’ needs – whether at group or individual level.
Our experience spans the full spectrum of healthcare consulting, from medical scheme selection and management to health insurance and gap cover solutions. As an organisation, we are committed to building long-term strategic relationships with our clients, so that we can consistently deliver the high standard of advice and service for which 4D Healthcare Consulting is renowned.
From everyday medical scheme gaps to complex actuarial requirements, 4D Healthcare Consulting provides practical expertise to help you make informed decisions, manage risk and ensure your healthcare benefits work effectively for both your people and your business.
Most people have a Medical Scheme to give you peace of mind that if you need medical care for any reason, your bills will be taken care of. Sometimes, however, approved hospital admissions can be costlier than the rate of cover provided by your chosen Medical Scheme option - which is why you need gap cover to ensure that you don’t receive a huge hospital bill if there’s a shortfall between what the doctors charge and what your Medical Scheme will pay for in-hospital procedures. 4D Healthcare Consulting have formed partnerships with a GAP Cover provider to ensure that we provide our clients with tailored solutions to meet your specific needs.
4D Healthcare Consulting has direct access to an independent actuarial firm. We have a long and successful working relationship with this service provider and make use of them when actuarial services are required. The most common service required annually by clients is the Post-Retirement Medical Scheme Liability (PRMSL) valuation and report, where employers are obliged to subsidise Medical Scheme contributions post retirement. This valuation assists the Financial Department of the client to determine the contingent liability that the employer faces in terms of IAS 37 of the International Financial Reporting Standards (IFRS). We have several clients that currently utilise this service.
Employee wellness has moved beyond the annual health day. We help clients think through the full picture - from medical scheme structuring through to financial wellness support and access to employee assistance resources - so wellness spend actually reduces absenteeism and turnover, not just ticks a box.
Gap cover tops up your medical scheme by covering the shortfall between what specialists charge and what your scheme pays. These questions explain what it does and doesn’t cover, and how the rules differ from a medical scheme.
Primary healthcare insurance products – such as Kaelo MyHealth, Discovery’s Flexicare and Momentum Health4Me – offer a lower-cost, insurance-regulated way to access day-to-day healthcare. These questions explain how this category of product works, what it does and doesn’t cover, and how it compares to medical scheme membership.
Gap cover is a short-term insurance policy that sits alongside your medical scheme and pays the difference — the "gap" — between what your scheme reimburses for specialist and hospital treatment and what the provider actually charges. It is designed to protect you from the out-of-pocket shortfalls that arise when a specialist's rate exceeds your scheme's reimbursement rate.
Yes. Gap cover is a top-up product, not a substitute for medical scheme membership — insurers require proof of active medical scheme membership before they will issue or pay out on a policy. If you cancel your medical scheme, your gap cover has nothing to top up and effectively stops being useful.
Most policies cover the shortfall between scheme rates and specialist or hospital account charges, scheme co-payments and deductibles on certain procedures, sub-limit top-ups where your scheme caps cover for a specific procedure, and in many cases a boost to oncology or casualty/emergency cover. Exactly what is included varies by insurer and by the specific policy schedule, so it's worth comparing wording rather than assuming all gap policies are identical.
Gap cover is not a day-to-day benefit — it will not pay for routine GP consultations, dentistry, optometry or over-the-counter medicine, and it cannot be used as a replacement for medical scheme cover. It also will not top up a claim your medical scheme has correctly rejected outright, as opposed to a claim your scheme paid but only at a reduced rate.
Yes. The Demarcation Regulations that govern gap cover set an annual claim limit per insured person, which is reviewed and adjusted periodically. Very large shortfalls on complex procedures can, in some cases, still exceed this annual cap, so it's worth checking your policy's current limit against the kind of treatment you're likely to need.
Under the Demarcation Regulations, insurers may apply a general waiting period of up to three months (during which only accident-related claims are paid) and a condition-specific waiting period of up to 12 months for anything you received advice, diagnosis or treatment for in the year before your policy started. These are maximum limits — insurers may apply shorter periods, but are not obliged to.
No. Gap cover is classified and regulated as short-term insurance under the Insurance Act and the Demarcation Regulations, not under the Medical Schemes Act, and it is authorised by the Financial Sector Conduct Authority (FSCA) rather than the Council for Medical Schemes. This matters because gap cover has no PMB obligation — an insurer is not legally required to cover a specific condition the way a medical scheme is.
This depends on the insurer — some will credit time already served on a substantially similar previous policy against their own waiting periods, while others won't. Always get written confirmation from the new insurer of exactly how your previous cover will be treated before you cancel your existing policy, so you're not left with a gap in cover.
Once your medical scheme has processed and paid (or partly paid) a claim, submit your scheme's statement showing what was billed versus what was paid, together with the relevant invoices and your policy number, to your gap cover insurer. For an in-hospital claim, also include your scheme's hospital authorisation letter — insurers generally ask for this alongside the claim documents. Most insurers ask for this within a set number of months of the original treatment date, so it's best to submit shortfall claims as soon as your scheme statement is available rather than waiting.
The NHI Act was signed into law with the goal of providing universal, publicly-funded healthcare access for all South Africans, funded through general taxes and mandatory contributions. Importantly, it does not replace private medical schemes immediately - implementation is happening in phases over several years, and for now, your existing medical aid continues to operate as normal. Over time, as NHI rolls out further, there may be changes to what private schemes are permitted to cover once NHI-funded services are available in a given area. Given how much is still being finalised through regulation, we recommend not making major changes to your medical cover based on NHI alone - we'll keep clients updated as implementation progresses and can advise on what it means for your specific situation.
Primary healthcare products - such as Kaelo MyHealth, Discovery's Flexicare and Momentum Health4Me - are insurance policies designed to cover routine, out-of-hospital healthcare costs like GP consultations, acute medicine and basic dentistry or optometry, for a fixed monthly premium that is typically far lower than medical scheme membership. Where an optional accident or emergency benefit is added, they can also pay towards in-hospital treatment for accidents, though this is separate, capped cover rather than comprehensive hospitalisation. They are aimed primarily at people who currently have no medical cover at all.
These products are underwritten by a licensed short-term or long-term insurer and regulated under the Insurance Act, not registered as a medical scheme under the Medical Schemes Act — so they carry no Prescribed Minimum Benefit obligation, aren't community-rated, and generally don't fund in-hospital treatment or specialist care for illness the way a scheme does. Providers say this plainly in their own documentation; Momentum, for example, states that "Health4Me is not a medical scheme product and is not a substitute for medical scheme membership."
Core day-to-day benefits generally include a set number of GP consultations (unlimited on some higher tiers, such as Flexicare Plus or Kaelo MyHealth Plus), acute and over-the-counter medicine, basic blood tests, and on richer plans, dentistry, optometry and management of a defined list of chronic conditions. Some plans also bundle limited accident, emergency or hospital cash benefits, but this is separate, capped cover - not comprehensive hospitalisation.
These plans don't fund planned or unplanned hospital admissions for illness, major surgery, oncology, or the broader range of specialist and PMB conditions a medical scheme is legally required to cover. Day-to-day benefits are also usually capped at a set number of visits or a rand value per year - for example, entry-level plans often limit GP visits to four a year - after which the member pays out of pocket.
Primary healthcare products suit people who want predictable, affordable access to a GP and basic medicine but currently can't afford, or don't have access to, medical scheme membership. They're not intended as a substitute for a medical scheme if you need, or can afford, comprehensive hospital and specialist cover.
Yes, this is possible - unlike a medical scheme, insurers offering these products can underwrite the policy, meaning your age, health and other risk factors can affect your premium, and specific benefits (or the policy itself) can be restricted or declined. Underwriting terms differ by insurer and product, so it's worth checking the specific plan's terms rather than assuming they're all the same.
Waiting periods vary by provider and benefit. As examples, Kaelo MyHealth typically applies a one-month general waiting period and up to six months for chronic medicine benefits, while Momentum Health4Me applies three-month waiting periods to benefits such as dentistry, optometry, HIV cover, hospital cash and funeral cover. Always confirm the current waiting periods on your specific plan before assuming a benefit is available immediately.
Most primary healthcare products route members through a designated GP or provider network to manage costs - visiting a provider outside that network, or skipping a required referral or pre-authorisation step, can mean a claim isn't paid or is paid at a reduced rate. Check your plan's network list and any referral rules before you need care, not after.
If you can afford medical scheme membership, a scheme generally offers broader legal protection - PMBs, community rating, guaranteed acceptance - that a primary healthcare product doesn't provide. These products are best understood as an accessible entry point for day-to-day healthcare, not a like-for-like substitute for a scheme; speak to an accredited adviser about which combination of cover suits your budget and health needs.
