Avoid the Dreaded Self-Payment Gap

December 1, 2024

As a medical aid member in South Africa, have you ever had to pay out-of-pocket medical expenses? Have you ever been disappointed to find that your medical aid will not cover the total bills for hospital stays and specialist consultation and the like? Have you been forced to fund a self-payment gap?

You are not alone. Thousands of South Africans have found that medical schemes sound great when you sign up. They mention figures like 100%, 200% and even 400% percent when you join. Naturally, you think you will have more than enough cover when you have to claim.

The reality is sobering.

Self-Payment Gap Statistics Not Available

Not surprisingly, the medical scheme industry (for an industry it is, although it is supposedly a non-profit industry) does not release shortfall payment statistics. It is safe to say, though, that if you have a hospital plan offered by a medical scheme or anything less than a top-of-the-range medical aid plan, you will have to pay hard cash to help cover your medical expenses if you land in the hospital.

Why Do Medical Aids Allow a Self-Payment Gap?

The medical schemes allow self-payment gaps because if they were to pay your bills in total, they would be bankrupt in no time at all. Hospital and specialist costs in South Africa are rocketing.

It all comes down the rates listed in the National Health Reference Price List (NHRPL) used by most medical aids. When a medical aid insures you for various procedures and products, the cover refers to this list. Thus your medical aid will pay 100% of the NHRPL rate, for instance, if you have that kind of plan. If that amount of money is less than the bill you receive, that’s tough luck. You have to pay it – unless you have bought into medical gap cover.

Medical Gap Cover is Brilliant

Self-payment gap cover is a South African innovation, and very smart it is too. For a small monthly premium (in comparison to monthly medical aid payments anyhow) you can be sure 1) the medical scheme plus 2) your gap cover insurer will settle your medical expenses in full. And the gap cover company will include everyone in your family listed as a member of the medical aid.

Now that’s peace of mind!

To requst your medical gap cover quote, just complete and send the form on this page

All info was correct at time of publishing