Expert Explains Medical Scheme Hospital Bill Limits and Gap Cover

December 18, 2021

One of the most common queries we receive is to explain the meaning of medical aid bill limits. And also why is it even necessary to have gap cover. In this article we will give a basic understanding of what both of these terms mean. Then based on this information you can make more informed decisions regarding gap cover and medical scheme hospital bill limits.




Annual Hospital Limits and Sub-Limits – Medical scheme hospital bill limits

medical scheme hospital bill limitsWhether you have an existing medical aid or you are considering which plan to adopt. Be sure that you are completely familiar with the hospital benefits offeredIn effect, this refers to the overall limit that your plan will pay on hospital-related claims. Although all South African medical aids must offer certain Prescribed Minimum Benefits (PMBs). To cover emergency medical care and a specified list of medical conditions, not all hospital costs will be covered. An extended or unexpected hospitalisation could well incur expenses. Even for such mundane things as hospital consumables. That will require payment not covered by your basic medical scheme.

Similarly, many medical aid packages have sub-limits on specified medicines, treatments or procedures. This means that the plan will only cover a certain percentage of some health options, while the rest must be paid for by yourself. Be particularly careful when choosing your plan, because sub-limits could well apply even if the scheme offers no overall annual limits!


How Can You Be Sure That You Can Pay Your Hospital Bills? – Medical scheme hospital bill limits

The best idea is to choose a medical aid that guarantees 100% cover with no sub-limits, but this is obviously not financially viable for many medical aid members. Fortunately, gap cover is now available to make up for any shortfalls in the existing medical aid payment scheme. Turnberry’s Maxi-Care range of gap cover policies, for example, are specially designed to complement those medical aid policies which specify sub-limits. The Maxi-Care range is available in two standard options:

  • Standard Maxi-Care: at only R105 monthly, this package offers R1 750 000 per family per year, over and above the limits of your particular medical scheme
  • Extended Maxi-Care: for R125 monthly, this package will pay up to R3 500 000 per family per year.


Turnberry also offers a more specialised range of products. The Execu-Care policy, for instance, offers a combination of gap cover options covering most conceivable situations. This affordable cover will apply to your entire family, and will be an investment in your family’s healthcare.

If you find yourself wondering whether or not to change your medical aid, there is an easy way to decide the best course of action. Simply add the monthly premiums of the Maxi-Care packet you want to your existing medical aid premiums. Compare the total to whichever comprehensive plan you are interested in. Whichever works out cheaper is probably the best option to take!


How Soon Will You Be Able To Claim?

There is often some kind of waiting period applicable before your gap cover will take effect.  This is usually three months for a standard policy, and nine months before maternity benefits become available. But if you apply for Maxi-Care simultaneously with your medical aid, your medical scheme’s waiting period will apply.

Fill in and submit the form on this page to get your one free medical gap cover quote!

All info was correct at time of publishing