What Are Medical Aid Co-Payments? Will Gap Cover Pay?

December 14, 2021

It is crucial that a member of a Medical Aid Scheme is aware of the rules of the scheme to avoid medical aid co payments. Medical schemes try to keep overall costs down. One of the ways they accomplish this is to apply co-payments for some procedures. That means that the patient must pay out-of-pocket. But there are ways to avoid medical aid co payments. Chief among these methods is to take out medical gap cover.

These co-payments are often for elective procedures i.e. hip replacements, colonoscopy, etc. Most medical aid schemes list explicitly in their brochures which procedures will require co-payments. The courts in 2011 ruled that a Medical Scheme must pay in full for any PMB (Prescribed Medical Benefit) as listed in the Medical Schemes Act.

There are requirements for full payment for PMB’s claims. (No co-payments)

  • Avoid Medical Aid Co PaymentsThe condition must be on the list from the act of PMB conditions
  • Treatments for each condition must be the same as listed and defined in the Act.
  • Members must use the schemes DSP (Designated Service Provider)
  • You have to pay the PMB treatments in full from the risk part of the scheme and not the members saving.
  • The PMB’s cover many chronic conditions as well as Emergency needs.
  • If the member uses a non-DSP other than in an emergency then, they can charge you a co-payment.


A case that came before the Medical Scheme Appeal Committee helps to illustrate the above:

  • Jan 1. The member was holidaying in the Cape and while hiking slipped and broke her shoulder. They took her to the nearest hospital as an emergency. She did fit the profile of a PMB condition of a closed fracture/dislocation or relocation of a limb. (Code 902H)
  • Jan 2 – After spending the night in hospital the member flew back to Johannesburg.
  • Jan 3 – The member saw an Orthopaedic Surgeon who advised she would need a Total Shoulder Replacement. Medical Aid authorization was given for the procedure, and she was advised of the level of claim reimbursements by the medical aid if she decided to use a non-DSP.
  • Jan 4- They surgery was at the non-DSP hospital which the patient had to stay in for four days.


The Medical Aid paid the bills related to the first hospitalisation in full. Short paid some of the claims for the 2nd hospital and requested a co-payment.

Avoid Medical Aid Co Payments

On appeal to the Council, they found that the Medical Aid had acted correctly. To replace a shoulder is not a PMB listed condition. Only relocation/dislocation /reduction of the shoulder. The procedure in Johannesburg was not of an emergency nature, and the patient could have gone to a DSP. Therefore the co-payments and shortfalls were correctly applied. It is advisable that members know their Medical Aid Scheme rules and unless it is an emergency situation contact their medical aid first to establish


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All info was correct at time of publishing