You have a good medical aid. You pay it faithfully every month. So how do you end up with a R28,000 bill after a routine operation? The answer is one of the least understood traps in South African healthcare, and it’s entirely avoidable.
The rate your scheme pays isn’t the rate you’re charged
Here’s the mechanism. Your medical scheme pays specialists at a fixed “scheme rate” (sometimes called the scheme tariff). But specialists (surgeons, anaesthetists, radiologists and others) are free to set their own fees, and many charge 200%, 300% or even up to 500% of that scheme rate.
The difference between what they charge and what your scheme pays is called the shortfall, and it lands squarely on you. On a single hospital admission with several specialists involved, that shortfall can run into tens of thousands of Rand.
A hip replacement, a caesarean, cancer treatment or even a bad accident can each generate a shortfall larger than most families keep on hand, and it arrives as an invoice weeks after you’ve gone home.
Where the shortfalls hide
Shortfalls aren’t only about specialist fees. Your scheme may also apply:
- Sub-limits: a capped amount for scopes, scans or internal prostheses like a hip or a stent
- Co-payments: a fixed amount you must pay upfront for certain planned procedures
- Benefit exhaustion: when an annual limit (oncology is a common one) runs out mid-treatment
Each of these can leave you paying, even on a comprehensive plan.
How gap cover closes it
Gap cover is a separate, relatively inexpensive insurance policy, often just a few hundred Rand a month for a family, that pays the difference between what your specialists charge and what your scheme pays, up to the limits set by law. It also typically covers those sub-limit shortfalls and co-payments.
Put simply: you keep your medical aid for the big in-hospital events, and gap cover mops up the shortfalls that medical aid was never designed to pay. For most families it’s one of the highest-value, lowest-cost policies they own, right up until the day it saves them R30,000.
Choosing the right gap policy
Gap cover products differ in what they include, their overall annual limit and how they treat things like casualty visits and cancer. Because gap cover is regulated as a separate product with its own rules, it pays to have someone compare the options against your medical scheme specifically. A good gap policy is one that plugs your scheme’s particular holes, not just any gap policy.
Don’t learn this in a hospital bed
Most people discover the shortfall problem the hard way, opening an unexpected invoice weeks after surgery, long after they thought the ordeal was behind them. It needn’t be that way. A ten-minute review now can tell you exactly how exposed you are, how large a shortfall your particular scheme could leave, and whether gap cover makes sense for your family. We’re glad to take a look at your current medical aid, compare it against the gap products on the market, and give you a straight, jargon-free answer, before life makes the decision for you.