Tony Singleton, CEO at Turnberry Management Risk Solutions

Many South Africans on top-tier medical aid plans believe they are fully covered for any medical event. However, while these plans offer broad benefits, access to private healthcare and higher reimbursement levels, this perception does not always reflect how medical aid cover works. Specialists frequently charge well above scheme rates, co-payments and sub-limits are increasingly common, and even comprehensive plans apply limits to what they will pay. The result is that you can still face significant out-of-pocket expenses, despite paying high monthly contributions. Gap cover plays a critical role in addressing these shortfalls by covering the difference between what medical schemes pay and what providers charge.

A false sense of security

Premium medical aid options are designed to provide extensive cover, and this often leads to the assumption that your plan will pay the full cost of treatment. This belief is reinforced by terms such as “100%” or “300% of scheme rate”, which can easily be misunderstood as synonymous with “full cover”.

In reality, these percentages refer to the medical scheme’s tariff, not the provider’s invoice. Specialists in fields such as oncology, orthopaedics and neurosurgery frequently charge up to five times the scheme rate, and sometimes more. Even on comprehensive plans, this creates a gap between what is charged and what your medical aid will pay. Having comprehensive medical aid does not remove your risk of shortfalls, it simply reduces it.

Where costs exceed cover

The most common out-of-pocket expenses on top medical aid plans arise from specialist shortfalls, co-payments and benefit limits. These are not limited to major procedures or even serious and complex cases. They can and do occur across a wide range of medical scenarios.

Procedures involving multiple specialists, such as surgery, can result in several separate shortfalls across surgeons, anaesthetists and assisting doctors. Oncology treatment is another area where costs can escalate quickly, particularly where schemes impose sub-limits on treatment protocols.

Co-payments have also become more prevalent as schemes manage rising healthcare costs. These can be required upfront before treatment proceeds and may amount to tens of thousands of Rands.

Understanding how medical aid pays for treatment and where shortfalls can arise helps to put these gaps into context. This makes it easier to see why additional cover may be necessary.

Making medical aid work harder for you

Gap cover is designed to work alongside medical aid, not replace it. While medical aid provides access to private healthcare, gap cover addresses the medical expense shortfalls that arise when scheme benefits do not fully match provider charges.

By addressing these shortfalls, gap cover helps to prevent you from having to use savings, take on debt or compromise long-term financial plans to cover for medical expenses. It also means that treatment decisions do not need to be dictated by what you can afford to pay out of pocket.

It is important to remember, however, that gap cover must be aligned with your specific medical aid option to ensure that it addresses the actual areas of exposure. Even on top-tier plans, this additional layer of protection has become an essential part of managing healthcare costs effectively.

Ensuring your cover works when it matters

Medical aid remains a critical part of accessing quality healthcare, but it does not eliminate financial risk, even at the highest levels of cover. Rising costs, higher specialist fees and evolving benefit structures mean that shortfalls are an ongoing reality.

Gap cover is a practical way to manage this risk by covering the difference between what medical schemes pay and what treatment actually costs. When structured correctly, it helps to ensure that a medical event does not become a financial setback.

Speaking to a broker or financial advisor can help you understand where your medical aid may fall short and how gap cover can be structured to provide the right level of protection for your needs.

ENDS