On average, South Africans fork out up to 20% of their monthly salary packages to medical aid cover, even with a 50% monthly contribution from an employer. The point of having private health cover in place is that it promises the very best quality of care when you really need it, which is not readily available in public facilities. There is, however, a misconception that medical costs will be fully covered if you are on medical aid, but statistics show this is seldom the case.

Regrettably, medical schemes no longer cover members for everything, and additional insurances are necessary to limit your exposure to exorbitant out of pocket expenses. The reasons for this is that South Africa’s private healthcare sector is characterised by an under-supply of medical specialists contrasted against medical schemes that are struggling to keep these specialist costs under control. The truth is that few medical schemes provide fully comprehensive cover for in-patient specialist care. This means that without supplementary cover, members potentially face large shortfalls between their medical scheme benefits and the actual costs incurred for surgery or other in-hospital treatment.

It is also important to understand what gap cover is and what it is not. Gap cover should not be viewed as replacing medical scheme cover but supplementing certain shortfalls that may occur. Essentially, gap insurance covers the potential shortfall that arises from specialist charges for in-hospital procedures. Specialists often charge up to 400% of the benefits offered by medical aid. So, if your medical scheme only pays out at 100% of tariff, you will then be liable for the shortfall of the other 300% out of your own pocket. This can amount to thousands of Rands and leave you in a serious financial predicament. Members are mainly at risk when it comes to in-hospital treatment or other serious treatments. Shortfalls of R30-40k are now commonplace whereas even a few years ago such high claims were rare exceptions

Supplementary products such as gap cover are available to offset such out-of-pocket medical costs and provide greater financial peace of mind in a health crisis. If you are considering a high deductible medical plan, or where you are opting for a lower benefit option on your medial aid to better manage costs, gap cover could prove to be invaluable.

Private medical scheme cover is complex and benefit designs are difficult to understand. Even for the more financially savvy, private medical scheme cover is difficult to compare as there are so many benefit variations. Deciphering exactly what you are or are not covered for is best done with the help of a professional broker by your side who can ensure that you don’t find out about any shortfalls in your cover when it’s too late.