Co-payment insurance covers medical aid shortfalls

December 18, 2021

Did you know that you could face a co-payment bill of R100 000 or more if you were in hospital and needed specialist care?

That is because your medical aid – even if it is an excellent plan from Discovery, Sanlam and so on – covers only a portion of hospital and specialist bills.

Why is that, you will probably ask, when your medical plan promises to cover anything from 100% to 500% depending on the plan?

The co-payment trick

When any medical aid refers to a percentage of cover, it is referring to the prices as they appear on the medical scheme’s own internal list price.

So if the list price says an appendectomy, for instance, should cost R50 000 but your final bill is R150 000, the medical aid will pay only R50 000. You will have to pay the shortfall amount.

This is a co-payment.

References to percentages in your medical plan are therefore misleading.

You could say it is a trick that medical schemes use to make you think that all your bases are covered.

But they are not.

Why doesn’t the medical aid pay in full?

The trouble is, hospital and specialists can charge what they like. And they do.

If a medical aid paid every cent owed to these providers, the medical schemes would soon run out of money.

That’s because hospitals and specialists would charge unacceptably high rates – just because they could.

What is more, the idea of National Health Insurance (NHI) is chasing specialists out of South Africa.

That means fewer specialists are available in the country.

And where there is growing scarcity, then prices rise.

They rise as high as they can.

That is why you need medical aid gap cover. Now.

What does it take to get gap cover?

  • You need to be a medical aid member of a medical scheme in South Africa.
  • There can be as many members on your plan as you like.
  • It can be any scheme at all, and any plan – from a hospital plan to comprehensive cover.
  • Your account must be in good standing.
  • You must be prepared to pay a monthly gap co-payment premium amounting to approximatey the equivalent of 10% of your medical plan.


What are the co-payment insurance options?

Short-term insurance companies offer gap cover (not medical aids, which are completely different.

As such they keep their products simple and with few options (again unlike medical aids!)

Here, for instance, are the 2024 offerings from Zestlife – for which you can request a personal quote on this page and sign up:

Zestlife Gap Cover 2024


Please get hold of Zestlife on this page (use the short form) so they can give you a custom quote for co-payment cover.

Act now!


All info was correct at time of publishing