For many South Africans, medical aid is seen as the foundation of financial protection when it comes to healthcare. However, a growing trend is highlighting an important reality: medical aid does not always mean full cover.
James White, Director of Sales at Turnberry Management Risk Solutions, notes that many patients are increasingly having to pay out of pocket despite being members of a medical scheme.
Understanding the Gap
The core issue lies in the difference between what medical schemes pay and what healthcare providers charge.
- Medical schemes typically pay between 100% and 200% of their own tariff rate
- However, specialists can charge up to 600% of that rate
The difference between these figures becomes the member’s responsibility, often resulting in significant shortfalls and financial distress after the hospitalisation.
“Gap cover exists specifically to address these shortfalls by covering the gap between what medical schemes pay and what healthcare providers charge”.
In fact, around 80% of gap cover claims relate specifically to these tariff shortfalls.
Rising Costs vs Household Income
A key concern for many households is that healthcare costs are rising much faster than income:
- Medical aid increases for 2026:
- Discovery: 7.2%
- Bonitas: 8.8%
- Medshield: 7.5%
- Bestmed: 6.8%
- Momentum: 9.9%
- Compared to:
- Inflation: approximately 3%
- Salary increases: typically 4–5%
- Healthcare cost inflation: 9–10% annually
This mismatch means that, in real terms, healthcare is becoming increasingly expensive for South Africans.
What This Means for You
To manage rising costs, medical schemes are increasingly:
- Introducing co-payments (which can exceed R30,000 upfront)
- Applying benefit limits and sub-limits
- Reimbursing strictly according to scheme tariffs
As a result, even comprehensive medical aid plans may leave members exposed—particularly during major medical events.
A Financial Planning Perspective
From a financial planning point of view, these shortfalls can have a real impact:
- Unexpected medical costs can disrupt savings plans
- Large once-off expenses may require accessing emergency funds
- Long-term financial goals (such as retirement planning) can be affected
Understanding these risks is a key part of building a well-rounded financial strategy.
How to Protect Yourself
Being proactive is essential. We recommend:
- Reviewing your current medical aid benefits in detail
- Understanding potential co-payments and limits
- Ensuring your healthcare cover aligns with your financial plan
Where appropriate, additional structures such as gap cover may help reduce exposure to unexpected medical expenses.
Final Thoughts
Medical aid remains a crucial part of healthcare funding in South Africa—but it is important to recognise that it is not a complete solution on its own.
By understanding the realities behind the numbers and planning accordingly, you can better protect yourself and your family from unexpected financial strain.
Source
Adapted from: Huge problem for medical aid members in South Africa – BusinessTech
BusinessTech. (2026) Huge problem for medical aid members in South Africa. Available at:
https://businesstech.co.za/news/finance/857068/huge-problem-for-medical-aid-members-in-south-africa/ (Accessed: 25 May 2026).
