Medical inflation in South Africa has consistently outpaced general inflation. While many employees receive annual increases of around four or five percent, healthcare costs often rise by nine or ten percent.
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Many South Africans assume that belonging to a medical scheme means their hospital treatment will be fully covered. In practice, this is often not the case.
Patients are increasingly encountering co-payments, specialist shortfalls and benefit sub-limits that leave them responsible for part of the bill. This happens because medical schemes pay according to their own tariff structures, while specialists often charge significantly more than those tariffs, sometimes as much as 500% of the scheme rate.
The difference between the scheme tariff and the provider’s invoice is then billed to the patient, and it can amount to tens of thousands of Rands. Gap cover exists specifically to address these shortfalls by covering the gap between what medical schemes pay and what healthcare providers charge, offering peace of mind and greater financial certainty.
Medical inflation in South Africa has consistently outpaced general inflation. While many employees receive annual increases of around four or five percent, healthcare costs often rise by nine or ten percent. Hospital tariffs, specialist fees and the cost of advanced medical technology continue to increase each year.
Medical schemes therefore face a difficult balancing act: keeping contributions affordable while managing rising provider costs. To do this, schemes increasingly rely on co-payments, tighter benefit limits and reimbursement based on scheme tariffs. For members, this means that belonging to a medical scheme does not always guarantee that every medical expense will be fully covered.
James White is a Director of Sales and Marketing at Turnberry Management Risk Solutions.
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One of the most common out-of-pocket expenses occurs when a healthcare provider charges more than the scheme rate. Medical schemes reimburse treatment according to their own tariffs, while specialists may charge several times that amount. This can create confusion for members, because policies often state that they pay “100% of the scheme rate”. In practice, this means the scheme pays up to its tariff limit, not the full amount charged by the provider.
From a gap cover perspective, this tariff shortfall accounts for the majority of claims. In many cases it represents roughly 78% to 80% of claims, making it one of the most common funding gaps patients experience.
Shortfalls are not the only challenge patients face – medical schemes increasingly rely on co-payments and sub-limits to manage rising healthcare costs.
A co-payment is a fixed amount that the member must pay before treatment takes place. Depending on the procedure and scheme rules, these amounts can range from around R5,000 up to R30,000, and in some cases even higher. For many households, being asked to produce this amount upfront can create significant financial strain.
Sub-limits can create a similar problem. Even when a procedure is covered, schemes may limit how much they will pay for certain treatments, scans or specialist services. Once the limit is reached, the remaining cost falls to the patient.
Because the system is complex, many clients only discover these gaps when they receive a bill after treatment. They assume their medical aid will cover the full cost of care, only to find that co-payments, benefit limits or specialist shortfalls still apply.
This is why it is important for advisers to explain clearly how medical schemes pay claims, particularly the difference between scheme tariffs and provider fees. When clients understand how these shortfalls arise, the role of gap cover becomes easier to understand. Rather than being seen as an optional extra, gap cover becomes part of the overall structure of healthcare cover alongside medical aid.
Healthcare funding in South Africa is unlikely to become less complex in the near future. As costs continue to rise, it is essential to understand how your medical scheme operates and where potential shortfalls may arise.
Many people only learn how their cover works when a claim is processed and an unexpected bill appears. Understanding the difference between scheme tariffs, provider fees, co-payments and benefit limits can help prevent these surprises.
Gap cover plays an important role in addressing these shortfalls by covering the difference between what medical schemes pay and what healthcare providers charge. Speak to a broker about what your medical aid covers, where shortfalls may occur, and how gap cover can help protect you from unexpected medical bills.
James White is a Director of Sales and Marketing at Turnberry Management Risk Solutions. The views expressed do not necessarily represent those of the Sunday Tribune or IOL.