Payment Shortfalls on Medical Aid Accounts

December 18, 2021

If you belong to a medical scheme, you’ll have the same queries many others have. You want answers as to why your medical aid seems to want to pay less and less for your treatments. You want to know about the payment shortfalls on medical aid.

Now even educational psychologists want answers. The Educational Psychology Association of South Africa (EPASSA) claims that some public and private medical aid schemes are refusing to pay for the services of this profession.

Massive Medical Aid Premiums Don’t mean No Medical Bills

Payment Shortfalls on Medical AidMedical aid schemes realise that they don’t have to cover the costs of educational psychologists. It means that heaps of school children will suffer and won’t be able to have their learning difficulties identified.

You’d think that because of the massive premiums medical aid members have to part with each month. They’d have their medical needs taken care of, but not at all. Not only are medical aids not paying for some treatments outright. But there are also some treatments that they only part-pay. Then you as the medical aid member have to pay for the shortfall.

Try and talk to your medical aid about this, and you’ll find that communicating with them just adds to the many challenges a member faces.

Don’t rely on your Medical Scheme – Payment Shortfalls on Medical Aid

The sad reality is that in South Africa people belong to medical aid’s to avoid the nightmare of going to a government hospital. Unfortunately, they’re not getting much joy from their medical aid’s either, and there is a word of advice. Do not rely on your medical aid – it’s not going to pay your medical bills in full.

Specialists and doctors can charge what they want, but your medical aid isn’t going to pander to this. The only light at the end of the tunnel is to have gap cover or medical top up the cover as some like to call it.

Most gap cover companies in South Africa are good, but still, it pays to compare. Every South African would surely prefer to pay R150 to R250 a month for gap cover than have to pay a bill of R100 000 to a doctor because your medical aid isn’t going to pay.

100% Coverage Doesn’t Mean Quite That – Payment Shortfalls on Medical Aid

When your medical aid tells you that you’re covered 100%, it’s not that simple. If your medical aid believes your operation should cost R10 000, 100% of the scheme rate means R10 000. The problem comes in when the specialist doing the operation charges R30 000, and your medical aid only pays R10 000. Without gap cover, you will have to pay the R20 000 shortfall. The simple reality is that ‘Specialists are charging far more than what medical aid schemes are willing to pay’.

Compare among the Reputable Gap Cover Providers

Medical gap cover isn’t medical aid. It is short term insurance. You have to belong to a medical aid to be able to buy gap cover. There are popular gap cover providers in South Africa such as Stratum and Zestlife among others.

If your medical scheme isn’t paying out at specialist rates, then all that is left for you to do is buy gap cover. Not doing so will mean you are covering the shortfall costs out of your pocket. Drive around South African suburbs on a Sunday afternoon and take note of all the ‘for sale’ boards – houses which belong to people without gap cover.

Many South Africans without gap cover have had to take this terrible route.  Selling their homes to pay for the shortfall that exists between what the hospital charges and what your medical aid is willing to pay. There’s a better alternative  – it’s called medical gap cover.


To get a FREE gap cover quote, fill in the form on this page and click on the “Get a Quote” button

All info was correct at time of publishing