Tariff Gaps in Medical Aid

December 18, 2021

Most South Africans know too well the sinking feeling of receiving huge bills when they believed their medical aid would settle the bill in full. Here we will cover what tariff gaps in medical aid are.

The truth is, your medical aid plan only pays out according to medical aid tariffs. Many doctors charge way above these tariffs. As a result, the patient is liable for the shortfall between what the scheme pays and what the doctor charges.

Sometimes these medical bills that you are liable for can be so outrageously high that they can cripple you financially so that you have to look at debt review or even liquidation.

Gap Cover – ensuring You’re Never out of Pocket

Tariff Gaps in Medical AidFortunately medical gap cover is an insurance policy that covers these differences between what some specialists charge and what your medical aid will pay. Gap cover is to ensure you’re never out of pocket with the tariff gaps in medical aid.

The truth in South Africa is that many doctors are contracted out of medical aid and charge fees well above medical aid rates. Your medical scheme such as Genesis, Bonitas, Selfmed, Discovery, etc. won’t pay private rate tariffs which are way beyond what the medical aid rates are set at.

Medical gap cover, however, will settle the difference once your scheme has paid the doctor, but there is a shortfall. Without gap cover, you would have to pay this shortfall.

Gap cover usually has a maximum percentage it will pay. Some of the lesser medical aid plans stop at around 300% while the most costlier plans will pay as much as 500%.

Mercifully, medical gap cover in South Africa is truly affordable with some of the lower plans starting at about R80 or R90  month. There are more comprehensive plans where you will pay R300 or R400 a month. It all depends on the plan you choose.

Guidelines regarding Tariff Gaps – Tariff Gaps in Medical Aid

Medical aid quotes will cover your in-hospital costs at 100% of the scheme tariff. The Department of Health has published tariffs for specific health services and procedures. These tariffs are the  National Health Reference Price List or NHRPL. Guidelines for specialists to follow when they charge medical aid members for procedures in a hospital.

For instance, if a specialist charges you  300%, you are being charged 3x more than the guidelines price.
Alway make sure you understand the tariff gaps in medical aid so that you don’t have to pay for some horrific shortfalls that have all the potential to cripple you financially.

To avoid shortfalls –

  • Get medical gap cover – it will cover the difference in cost, up to 300%
  • gap cover can range from R400 to R600 per month for an individual or the whole family
  • look to join a scheme that covers at 300% or more which means you won’t have to negotiate with specialists
  • call your scheme for pre-authorisation and find out how much they will pay for your treatment

Here is the 2024 Zestlife price list for your attention:

Zestlife Gap Cover 2024


As a medical scheme member you no doubt expect your costs to have cover – in full. That doesn’t happen, though. Medical scheme benefits limits to their Medical Scheme Tari­ffs (MST). With specialists charging more than MST, it creates a shortfall, and someone needs to pay for this. Without gap cover it’s you.

Got queries about gap cover? WellSpent has got professional advisors who will answer all your questions – no cost!

So take out medical gap cover – it’s not expensive. And the costly procedures won’t become your ultimate nightmare.


To get a FREE gap cover quote complete the form on this page 

All info was correct at time of publishing