Kaelo Gap Cover (2026)

Kaelo Gap Cover provides additional financial protection for certain medical expense shortfalls that remain after a medical scheme has processed a qualifying healthcare claim.

For 2026, Kaelo offers two gap cover options:

• Kaelo Gap Core
• Kaelo Gap Optima

Both options have an Overall Annual Limit of R219,845 per insured party per year for Core Benefits. Optima provides broader benefits in several areas, including higher tariff shortfall cover, oncology benefits, co-payments, non-network hospital penalties and casualty-related benefits.

Kaelo Gap Cover is not a medical scheme, and the cover is not the same as medical scheme cover. It is not a substitute for medical scheme membership. 

📌 Download Kaelo Brochure 2026 here

Kaelo Gap Cover 2026 at a Glance

The Overall Annual Limit is the maximum combined amount payable for Core Benefits. It should not be interpreted as R219,845 being available separately for every benefit.

How Much Does Kaelo Gap Cover Cost in 2026?

Current 2026 Kaelo Gap Cover premiums must be confirmed from an official Kaelo premium schedule or quotation before publication.

Contact Kaelo Gap Cover at:  Kaelo Gap 0861 493 587 / [email protected]

When comparing Core and Optima, price should also be considered alongside the differences in tariff protection, oncology benefits, sub-limit cover, casualty benefits and co-payment protection.     

What Is Kaelo Gap Cover?

Gap cover is designed to complement medical scheme membership.

A shortfall can occur when a healthcare professional charges more than the amount your medical scheme pays. For example, a surgeon, anaesthetist, pathologist or radiologist may charge above your scheme's reimbursement rate.

Where the event meets the Kaelo policy requirements, gap cover can provide benefits toward qualifying shortfalls.

It does not mean that every unpaid medical bill is automatically covered.

📌 Read more about the best gap cover providers in South Africa

Kaelo Gap Core vs Kaelo Gap Optima

The biggest difference between Core and Optima is the breadth and level of protection.

Kaelo Gap Core

Core concentrates on several key shortfall benefits, including:

• Tariff shortfalls
• Shortfalls from sub-limits
• Out-of-hospital tariff shortfalls
• Dental reconstruction
• Hospital Booster
• Family Protector
• Medical Scheme Contribution Waiver
• Gap Cover Premium Waiver
• Road Accident Fund claims assistance

Core provides an additional 500% of the medical scheme rate for qualifying hospital tariff shortfalls.

Kaelo Gap Optima

Optima includes the Core-type shortfall protection but adds a broader set of benefits, including:

• Co-payments and deductibles
• Oncology tariff shortfalls
• Oncology sub-limits
• Oncology co-payments
• Penalty co-payments
• Innovative oncology medicines
• First-time cancer diagnosis benefit
• Family Booster
• Child Casualty Illness
• Accidental Casualty
• Casualty Emergency

Optima also increases tariff shortfall protection to an additional 600% of the medical scheme rate.

Kaelo Tariff Shortfalls

Tariff shortfall cover applies to qualifying medical expense shortfalls during a Hospital Episode.

This can include healthcare professionals such as:

• Surgeons
• Radiologists
• Pathologists
• Physiotherapists

The 2026 cover is:

Prescribed Minimum Benefits and Kaelo Gap Cover

Prescribed Minimum Benefits are minimum benefits that qualifying medical scheme members are entitled to under South African medical scheme legislation.

Kaelo's 2026 tariff shortfall benefit includes qualifying PMB-related shortfalls.

However, this does not replace the medical scheme's PMB obligations or override the scheme's rules.

Medical schemes may still apply requirements relating to:

• Pre-authorisation
• Clinical protocols
• Formularies
• Designated Service Providers
• Network arrangements

Kaelo Gap Cover remains separate insurance and is assessed according to its own policy terms and insured events.

Out-of-Hospital Tariff Shortfalls

Both Core and Optima provide qualifying out-of-hospital tariff shortfall cover.

There is an important condition.

The outpatient procedure must be funded from the medical scheme's risk or hospital benefit.

This means members should not assume that an ordinary GP consultation or expense paid from a Medical Savings Account will qualify.

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Co-Payments and Deductibles

Kaelo Gap Optima provides cover for diagnostic and medical procedures where the medical scheme applies a fixed rand-value co-payment.

This benefit is limited to the Overall Annual Limit.

Co-payment protection should not be interpreted to mean every amount requested by a medical scheme will qualify. The medical procedure and claim still need to meet the policy requirements.

The Core Summary does not list this benefit.

Non-Network Hospital Penalty Co-Payments

Kaelo Gap Optima includes protection for qualifying penalty co-payments or deductibles where a member voluntarily uses a non-network hospital.

The benefit provides cover of up to 30%, limited to:

• Two events per family per year
• Maximum of R19,660 per event

This can be relevant for members of medical aid options with restricted hospital networks.

For example, an option may require members to use selected Netcare, Mediclinic, Life Healthcare or independent hospitals.

Members should still check their medical scheme's hospital network before admission. Gap cover should not be treated as a reason to disregard network restrictions.

The Core Summary does not list a Penalty Co-Payment benefit.

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Kaelo Oncology Benefits

Oncology is one of the areas where Optima differs substantially from Core.

Optima includes:

• Oncology tariff shortfalls
• Oncology sub-limits
• Oncology co-payments
• Innovative Oncology Medicines
• First-time cancer diagnosis
• Dental reconstruction following qualifying cancer treatment

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Oncology Tariff Shortfalls

Optima provides additional cover of up to 500% of the medical scheme rate for qualifying oncology treatment shortfalls.

The scheme must still process and fund its applicable portion according to the policy requirements.

Oncology Sub-Limits

Where approved oncology treatment exceeds the medical scheme's applicable oncology sub-limit, the benefit can cover the difference between the amount charged and the amount paid by the medical scheme, subject to the Overall Annual Limit.

Oncology Co-Payments

Kaelo Gap Optima provides cover for the 20% oncology-related co-payment applied by a medical scheme, subject to the policy terms and Overall Annual Limit.

Innovative Oncology Medicines

Optima provides qualifying cover for Innovative Oncology Medicines as defined by the insured person's medical scheme.

The benefit is the lesser of:

• 25% of the total drug cost, or
• R15,100

This is not unlimited cancer drug cover.

First-Time Cancer Diagnosis Benefit

Kaelo Gap Optima provides an agreed benefit of R15,000 for a qualifying first-time cancer diagnosis equivalent to stage 2 or higher.

The benefit is limited to:

• One claim per insured party
• Over the lifetime of the policy

The official comparison brochure states that it excludes a form of cancer that was previously identified or required treatment.

The Core Summary does not list this benefit.       

Child Casualty Illness

Qualifying after-hours emergency outpatient treatment in a hospital casualty ward is covered for children under age 12.

The benefit is limited to:

• Two events per year
• R3,300 per event

After-hours are defined as:

• Monday to Friday: 18:00–08:00
• All day Saturday
• All day Sunday
• South African public holidays

Casualty Emergency

This applies to qualifying illness-related emergency outpatient treatment in a hospital casualty ward.

It is limited to:

• One event per policy per year
• R2,600 per event
• Insured parties aged 13 and older
• After-hours treatment

The official Optima document states that where payment is made from an available Medical Savings Account or directly by the member, the relevant qualifying amount may also be refunded according to the benefit terms.

Family Booster

Kaelo Gap Optima provides a R15,900 agreed benefit when a qualifying Premature Birth occurs.

Kaelo's maternity guidance defines the example as a premature birth occurring 41 or more days early.

The benefit is not listed under Core.

Hospital Booster

Both Kaelo options provide a Hospital Booster linked to the length of a hospital stay following an accident or Premature Birth.

A maximum of two Hospital Episodes per family per year applies.

Optima provides slightly higher daily benefits and a higher annual maximum.

Lifestyle Benefits

Kaelo offers optional Lifestyle Benefits at an additional fee.

These include:

AskNelson Services

Services include:

• Virtual counselling
• Face-to-face counselling
• Telephonic counselling
• Life coaching
• Managerial coaching
• Parent coaching
• Workplace trauma interventions
• Financial advice
• Legal advice
• Assistance with Road Accident Fund claims

Dis-Chem Better Rewards

Members who opt into the Lifestyle Benefits can qualify for Dis-Chem Better Rewards, with Kaelo stating instant savings from 20% on selected everyday products.

These Lifestyle Benefits are optional and carry an additional fee.

📌 Read more about Dischem Gap Cover

Kaelo Gap Cover Waiting Periods

The official Core and Optima 2026 summaries state the standard waiting periods as:

• 3-month General Waiting Period
• 12-month Condition-Specific Waiting Period

These can materially affect new members, particularly where medical treatment is already planned.

Employer Group Waiting Periods

Different rules can apply to employer groups.

Kaelo's 2026 documents state:

• Waiting periods are determined when the group is taken on.
• Waiting periods may be applied, reduced or waived.
• Policyholders joining voluntarily through an employer group receive full waiting periods.
• Compulsory groups have all waiting periods waived.

Waiting Period Concessions

For applicable employer-group concession periods:

• The 3-month General Waiting Period can be waived.
• The 12-month condition-specific exclusion still applies.
• Concessions are negotiated between the broker and Kaelo.
• Concessions apply only to employer groups.

This distinction is important. Individual applicants should not assume that employer-group concessions automatically apply to them.

Kaelo Gap Cover and Maternity

Kaelo Gap Optima's official 2026 document provides practical examples of how its existing benefits can apply to maternity-related events.

These are not separate maternity benefits.

Examples include:

For specialist fees relating to a baby's hospitalisation, Optima can provide up to an additional 600% of the medical scheme rate, subject to the applicable terms and Overall Annual Limit.

📌 Read more about Turnberry Gap Cover Options 

How to Claim From Kaelo Gap Cover

Kaelo requires the following documents for a gap-cover claim:

1. Completed Kaelo Gap Claim Form
2. Specialist account or accounts
3. Hospital accounts
4. Medical scheme statement showing how the account was processed and the shortfall

How Long Do You Have to Submit a Claim?

A claim must be submitted within six months from the end of the Insured Event.

Kaelo states that claims received after this six-month period will not be accepted.

How Long Does a Kaelo Claim Take?

Once all required documents have been received, Kaelo states that a valid claim will be assessed within:

7–14 working days

The claim process then progresses through reference, processing, authorisation and payment.

What Does Kaelo Gap Cover Not Cover?

Kaelo's official 2026 summaries contain several important exclusions.

Claims caused by or related to the following are listed as excluded:

• A claim excluded or rejected by the medical scheme where the scheme has not paid its portion toward the relevant line item
• A claim that is not a registered benefit of the medical scheme but was paid ex gratia
• Split Billing
• Infertility treatment or procedures
• Treatment outside the period of an Insured Event
• External prostheses
• Appliances such as wheelchairs, beds and convalescing equipment
• Specialised dentistry
• Harvesting or preservation of human tissues
• Breast enlargement
• Gastroplasty
• Lipectomy
• Otoplasty
• Gender reversal procedures
• Therapeutic massage therapists
• Rehabilitation
• Frail care
• Hospice services
• Step-Down Facilities
• TTO medicines

The summary documents specifically note that the Split Billing exclusion does not apply to Balance Billing.

Members should consult the full Kaelo policy document for the complete exclusion list.

Who Is Kaelo Gap Core Best Suited For?

Kaelo Gap Core may suit medical scheme members who want protection against some of the most common medical expense shortfalls without needing the broader Optima benefit set.

Core is particularly relevant for members focused on:

• Hospital tariff shortfalls
• Out-of-hospital tariff shortfalls
• Sub-limit protection
• Accident-related dental reconstruction
• Hospital Booster benefits
• Family protection
• Medical scheme contribution protection

Its tariff protection is an additional 500% of the medical aid rate, compared with 600% on Optima.

Who Is Kaelo Gap Optima Best Suited For?

Kaelo Gap Optima may be better suited to members looking for broader shortfall protection.

Compared with Core, Optima adds or enhances areas such as:

• 600% tariff shortfall protection
• Co-payments
• Oncology benefits
• Non-network hospital penalties
• Innovative cancer medicines
• First-time cancer diagnosis
• Casualty benefits
• Premature birth benefits
• Higher sub-limit protection

Members should still compare these benefits with the reimbursement level, hospital network and co-payment structure of their actual medical aid option.

Kaelo Gap Core vs Optima: Which Is Better?

Optima provides the broader benefit structure.

It gives an additional 600% of the medical aid rate for qualifying tariff shortfalls versus 500% on Core and doubles the specified sub-limit protection from R34,450 to R68,370.

Optima also provides oncology, casualty, co-payment and non-network penalty benefits that are not listed in the Core Summary.

Core remains relevant for members who primarily want protection against tariff and sub-limit shortfalls.

The final decision should also include the monthly premium, but the official 2026 documents used for this review do not contain premium amounts.

Kaelo Gap Cover Pros and Limitations

Frequently Asked Questions

What Kaelo Gap Cover plans are available in 2026?

Kaelo's official 2026 documents list Kaelo Gap Core and Kaelo Gap Optima.

What is the Kaelo Gap Cover annual limit?

The Overall Annual Limit for Core Benefits is R219,845 per insured party per year. This is the maximum combined benefit payable for applicable Core Benefits.

How much tariff cover does Kaelo provide?

Kaelo Gap Optima provides an additional 600% of the medical aid rate for qualifying tariff shortfalls. Core provides an additional 500%.

Does Kaelo cover out-of-hospital procedures?

Yes. Optima provides up to 600% and Core up to 500% of the medical scheme rate for qualifying outpatient procedures, provided the costs are funded from the medical scheme's risk or hospital benefit.

Does Kaelo Gap Cover co-payments?

Optima provides cover for qualifying co-payments and deductibles relating to diagnostic and medical procedures. The Core Summary does not list this benefit.

Does Kaelo cover non-network hospital penalties?

Optima provides qualifying cover of up to 30% for penalty co-payments or deductibles arising from voluntary use of a non-network hospital. It is limited to two events per family per year and R19,660 per event.

Does Kaelo provide oncology cover?

Optima includes oncology tariff shortfalls, oncology sub-limits, oncology co-payments, Innovative Oncology Medicines and a first-time cancer diagnosis benefit. These benefits are not listed in the Core Summary.

Does Kaelo Gap Cover dental work?

Kaelo provides a dental reconstruction benefit where surgery is required as a direct result of qualifying accidental injury or cancer treatment. It is not general dental cover.

What are the Kaelo Gap waiting periods?

Kaelo's 2026 summaries state a 3-month General Waiting Period and a 12-month Condition-Specific Waiting Period.

Can I switch from another gap cover provider?

Yes. Kaelo states that avoiding a break in cover is important. Where there is no break, unexpired waiting periods may carry over, while members who have already completed their previous waiting periods may have no new waiting periods applied.

How long do I have to submit a Kaelo claim?

Claims must be submitted within six months from the end of the Insured Event.

How long does Kaelo take to process a claim?

Once all required documents have been received, Kaelo states that valid claims are assessed within 7–14 working days.

Does Kaelo cover medical treatment outside South Africa?

The benefits described in the 2026 summaries apply only to services rendered within the Republic of South Africa. Services outside South Africa are excluded from those benefits.

Is Kaelo Gap Cover a medical aid?

No. Kaelo Gap Cover is insurance that supplements medical scheme membership. It does not replace a registered medical scheme.

Kaelo Gap Cover Contact Details

Kaelo Service Centre: 0861 493 587
WhatsApp: +27 66 433 6768 — no calls
Email: [email protected]

Regulatory Information

Kaelo Gap is administered by Kaelo Risk (Pty) Ltd, an authorised Financial Services Provider, FSP 36931.

Kaelo Gap is insured by Centriq Insurance Company Limited, a licensed non-life insurer and authorised Financial Services Provider, FSP 3417.

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