Members on higher-end medical aid plans often assume they are covered for any eventuality, until it is time to claim for a significant medical event.
Consumers plan for retirement, save for their children’s education, join a medical aid and try to build a financial cushion, but they often forget about the medical co-payments that chip away at those plans, year after year.
It starts small with a R5 000 co-payment for a scope examination. Then a few months later, you have to fork out a R12 000 shortfall for a hospital admission. Fast forward five years and you spent tens of thousands of rands on out-of-pocket medical costs that your medical aid did not fully cover.
Medical aid shortfalls could increase your debt
That is why Tony Singleton, CEO at Turnberry Management Risk Solutions, warns that medical aids cannot keep pace with the rate of medical inflation while still maintaining affordable premiums, making co-payments grow each year, while more sub-limits are introduced and specialist fees continue to outpace medical aid rates.
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“This means more and more South Africans are finding themselves forced to withdraw money from their retirement funds or take on debt to cover medical aid shortfalls. Medical aid alone is no longer enough to protect your financial future, which is why gap cover has become essential.
“Even comprehensive plans can fall short when it comes to specialist charges, hospital procedures, or newer, high-tech treatments. Many specialists charge as much as five or six times the scheme rate and certain procedures have limits to what medical aids will pay or require as an up-front co-payment. While your medical aid might pay a portion, the rest becomes your responsibility.”
He says this can become a compounding problem as what starts as a few isolated bills adds up. Over time, shortfalls from surgeries, diagnostics, scopes, chronic illness treatment or specialist consultations can add up to hundreds of thousands of rands.
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Examples of how much copayments could be on medical aid
For example, one Turnberry client who suffers from spinal conditions, lupus and gastro-oesophageal reflux disease (GERD) claimed R478 000 across 27 incidents in only five years. Another claimed R450 000 across 54 incidents related to lung disease and spinal conditions, while a third, with multiple chronic issues, received over R448 000 in gap cover payments over the same period.
“As the years go by, these amounts continue to add up and this is becoming an increasingly typical pattern. Many families are forced to pause investments, take out loans, or use money from their retirement annuities to keep up with these uncovered and unanticipated expenses.”
This shows why gap cover has become essential. Gap cover was created precisely to tackle these medical expense shortfalls with an affordable policy that sits alongside medical aid and offers cover for medical expense shortfalls, co-payments, sub-limit cover, oncology shortfalls, prosthesis costs and even casualty visits. Where medical aid benefits have tightened to control premiums, gap cover has expanded to fill the void, Singleton explains.
“Many South Africans still believe gap cover is a nice-to-have or something that is only necessary later in life. However, the reality is that shortfalls affect people no matter what age they are, from broken bones in their twenties to maternity bills in their thirties or chronic conditions emerging in their forties and beyond.
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Joining medical aid early makes a difference
“Joining early also makes a difference, as you are covered from the start and your premiums will remain lower than someone beginning their cover at 65, when age-based premium increases and health exclusions may apply.”
Singleton also points out that gap cover is not just for major surgeries or cancer treatments.
“It is also valuable for more routine procedures as well as accidents and emergencies. In addition, its value increases over time, especially if you remain continuously covered and avoid reintroducing waiting periods.”
By staying on gap cover year after year, members build a stable financial buffer against the cumulative effect of medical costs, Singleton says. “We have seen clients rely on gap cover for decades of health events, not just once-off emergencies and the value of continuous cover is evident in our lifetime claims figures.
“Gap cover is no longer a luxury, it is an essential tool for building long-term financial resilience. Without it, medical aid shortfalls can easily undo years of careful financial planning.”