Why Do Co-Payments Occur When You Have Medical Aid?

December 14, 2021

Why do co-payments happen? Where do they come from? If I have medical aid membership, why do I have to make co-payments? What are co-payments and are they avoidable?

What are co-payments?

Sometimes your medical aid decides that it won’t pay your entire medical bill – or perhaps any portion of the bill – and let’s you know you have to pick up the tab, or make a co-payment i.e. share the costs.

Anyone in South Africa who belongs to a medical scheme knows the feeling. Your medical savings account funds run out (this happens a lot toward the end of the calendar year) or your medical aid lets you know you need to help foot a medical bill.

But why do these co-payments arise? What are co-payments, in fact?

Explanation of copay

It’s like this: you are on a medical aid and the paperwork say you are covered for “100%, 200%, 300%” etc. of expenses, which sounds great – so great that you think you might finish the year in profit!

That’s totally wrong, because there is an underlying situation which mitigates against you scoring on any deal with a medical aid. This is because of the medical tariff lists according to which these schemes work.

Let’s say you have a medical procedure and the bill you receive is R9000. You send this to the medical aid expecting them to cover it in total – because, after all, you are covered at least 100% according to the paperwork. (Some plans even pay up to 500%.)

However, the medical aid is not interested in the bill you receive. Instead they refer to their internal tariff list to find out what the procedure figure is there. Say the figure is R6500. Well then, the medical aid will pay the provider or providers R6500 and not a penny more. In this case you would have to pay out R2500 of your own money to make up the shortfall.

This doesn’t sound too bad – but what happens if you need heart surgery or cancer treatment, which is horribly expensive now days. The same principle applies and that means you could be stuck with co-payments of hundreds of thousand rand.

The solution

There is a solution – gap cover insurance also called shortfall cover or top-up insurance. This inexpensive short-term product ensures that you will never have to make a co-payment again!

Get a quote now by completing the form on this page. Discover how a low monthly premium can relieve the burden of medical aid co-payments.

All info was correct at time of publishing