Craig Comrie, Chief Executive Officer of Profmed

There is a growing misconception among insured South African professionals that gap cover is essential to avoid being left out of pocket in the event of a claim. While gap-based products certainly have a place in the local market, they are not a blanket solution – and in many cases, upgrading to a more comprehensive medical scheme plan can provide the same, if not better, protection.

The rising popularity of bundled health-cover solutions reflects a broader reality. Healthcare provider costs along with fantastic but expensive new medicines have consistently outpaced inflation, and at the same time, more members are living longer and making use of healthcare services. Medical schemes’ member bases are ageing, and older people naturally require more healthcare.

Alongside this growing utilisation of benefits, there is a shortage of specialists. This scarcity allows many specialists to charge significantly more than scheme rates – sometimes two or three times more, and in extreme cases even higher. The introduction of new technologies at the point of care further contributes to these rising costs, creating opportunities for gap cover and other supplementary products to help members flex the cover they need.

It is important, however, to fully understand what gap cover is and how it came about. Initially, the Council for Medical Schemes questioned the role of such products under the Medical Schemes Act, as it appeared to duplicate the functions of a medical scheme. After years of what became known as the “demarcation debate”, it was agreed that gap cover is an insurance-based product designed to cover shortfalls between what a medical scheme pays and what a provider charges.

This distinction is important because gap products and medical schemes are designed very differently. Gap products operate as insurance policies sold for profit, whereas medical schemes are member-owned funds. By law, medical schemes are not allowed to make profits – any surplus is reinvested for the benefit of members. The only purpose of a medical scheme is to pay the claims for services that members use.

Gap cover then comes into play when a medical scheme has funded part of a claim and the provider charges more than that reimbursement. It can be very useful in such cases but remains a supplement – not a substitute – for a comprehensive medical scheme.

Notably, most medical schemes have options that cover more than 100% of the normal rate paid to specialists. At Profmed, for example, we offer an affordable option that covers 175% of the rate, which means on average your claim will get paid in full. From there, we move up to 200% and 300% – all within the scheme itself.

Furthermore, schemes generally pay over 85% of all the claims submitted. At Profmed, we average close to 97%, which should give members and those seeking medical cover confidence that belonging to a medical scheme typically ensures their claims are funded and care is provided. The implication is that there is only a very small case for GAP products, if you choose the right cover with your medical scheme. While some GAP products cover up to 500%, the Profmed experience is that there are less than 5% of providers that charge more than 200% of the accepted medical scheme rate and if a person only asks a provider what they charge, many will reduce their rates to more acceptable levels.

What truly sets Profmed apart, however, is our deep understanding of South Africa’s professional community. The scheme was created specifically for professionals and continues to evolve with their needs, offering tailored healthcare solutions that recognise the unique pressures, risks and lifestyles of working South Africans.

Profmed also places strong emphasis on guidance and the education of healthcare consumers. Through clear communication, regular engagement and practical tools, the Scheme helps members make informed decisions about their healthcare – including whether to upgrade a medical scheme plan or buy an external gap product. For professionals considering how best to protect themselves, this understanding is key to choosing the right combination of cover and making confident, informed decisions about their healthcare.

ENDS