It’s a scenario playing out across South Africa every day: You’re diligent with your medical aid payments. You go in for a necessary procedure. Everything gets approved. Then comes the gut punch: a bill for R20,000 that your medical aid won’t cover.
That begs the question: How is this possible with comprehensive medical aid?
Well, the truth is that comprehensive plans leave significant gaps between what they pay and what you’re liable for. Understanding medical aid shortfalls is the first step toward protecting your financial future.
Why Medical Aid Doesn’t Fully Cover Your Hospital Bills
Medical aids operate on predetermined tariff rates—the maximum amount they’ll pay for hospital procedures, specialist fees, and medical care. If specialists charge above-tariff rates, and your medical aid only pays up to their scheme rate, it will leave you responsible for the medical aid shortfall.
This gap exists across all medical schemes in South Africa, regardless of how much you pay monthly. Medical inflation continues to outpace medical aid rates, creating an ever-widening financial gap that catches patients off guard.
Medical Shortfalls and “Hidden Costs”
Medical aid shortfalls don’t come from a single source. Multiple factors contribute to uncovered and unanticipated expenses:
1. Specialist Fees Above Medical Aid Rates
Although some specialists charge medical aid rates, others may charge 200% to 700% above what medical aid pays. This could apply to surgeons, anaesthetists, physicians, and consultations. Even when your medical aid approves the procedure and processes the claim, they pay only their predetermined rate.
2. Co-Payments and Deductibles
Many medical aids impose an up-front co-payment for certain procedures—gastroscopies, colonoscopies, scans, and hospital admissions. This upfront co-payment can range from R5,000 to R15,000 before your medical aid benefits even apply.
3. Sub-Limits on Specific Procedures
Medical aids set annual caps (sub-limits) on expensive items like internal prosthesis costs, MRI/CT/PET scans, and specific high-tech treatments. Once you hit these limits, you’re fully responsible for additional costs—even if medically necessary.
4. Out-of-Network Provider Penalties
Using a non-designated service provider often triggers additional co-payments or reduced coverage, creating larger medical shortfalls.
5. Theatre, Ward, and Equipment Fees
Hospital facility charges for theatres, private wards, and specialised equipment often exceed what medical aid pays, adding thousands to your medical bills.
6. Prescribed Minimum Benefits (PMB) Gaps
Even for conditions legally required to be covered, medical aids sometimes pay only at scheme rates, leaving shortfalls when providers charge more.
Who Gets Hit With Medical Aid Shortfalls?
The assumption that only people on entry-level medical aids face shortfalls is dangerously wrong. Medical aid shortfalls affect people across all income levels and plan types.
High-Risk Groups Include:
- Families with chronic conditions emerging (e.g. diabetes, hypertension, lung disease, gastro-oesophageal reflux disease)
- Patients requiring chronic illness treatment with ongoing specialist consultations
- Cancer patients facing oncology shortfalls that exhaust annual limits
- Pregnant women with maternity bills exceeding basic coverage
- Emergency cases where even casualty visits trigger co-payments
- Patients with multiple chronic issues requiring frequent hospital procedures
- Individuals undergoing major surgeries like joint replacements or cardiac procedures
- Anyone requiring high-tech treatments or prosthetic costs
The Gap Cover Solution: Sits Alongside Medical Aid
Gap cover is an essential tool designed specifically to cover medical aid shortfalls. It’s not a replacement for medical aid, but an insurance policy that sits alongside it to create a safety net.
How Gap Cover Works
When you have a hospital procedure:
- Your medical aid pays its portion at the scheme rate
- The gap cover policy covers the difference between medical aid rates and actual charges
- Gap cover payments go directly to you or the provider
- You avoid out-of-pocket medical bills
Gap Cover Benefits That Address Common Shortfalls
- Tariff Shortfall Coverage: TRA’s gap cover provides up to 700% above medical aid rates for hospital procedures—covering the gap where specialists charge significantly more.
- Co-Payment Cover: Covers the upfront co-payments and deductibles that medical aids impose on certain procedures and hospital admissions.
- Sub Limit Cover: When you’ve exhausted medical aid sub-limits for scans, prostheses, or other capped benefits, gap cover steps in.
- Oncology Protection: Cancer treatments often generate the largest medical shortfalls. Gap cover provides oncology shortfall coverage, co-payment protection, and extender benefits when annual limits are reached.
- Casualty Coverage: Even casualty visits for accidents can trigger shortfalls—gap cover includes casualty benefits.
- Maternity Coverage: Maternity bills frequently exceed medical aid coverage. Gap cover helps cover shortfalls during pregnancy and childbirth (subject to waiting periods).
Maintaining Continuous Cover
One often-overlooked aspect of gap cover is the importance of maintaining continuous cover. Here’s why clients rely on this principle:
Avoid Reintroducing Waiting Periods: If you cancel and reapply later, you face new waiting periods of potentially 10 months for major surgeries, pregnancy, and chronic conditions emerging.
Building Lifetime Claims Figures: Staying continuously covered means that when you need gap cover most, you’re protected without delays.
Long-term Financial Resilience: Gap cover creates a stable financial buffer against the unpredictable nature of health events throughout your life.
Affordable Premiums That Protect Your Future
Gap cover provides substantial protection while maintaining affordable premiums. TRA’s gap cover starts from R99 per month for individuals, which is a small investment compared to potential medical shortfalls of tens of thousands of rands.
The strategy of carrying gap cover year after year, even when healthy, ensures you remain continuously covered and protected when unexpected health events occur. This approach to careful financial planning creates a financial cushion that protects family members from devastating medical bills.
TRA Gap Cover Plans: Choose Your Protection Level
- Basic Cover 300 (R99/month) – 300% tariff coverage with casualty and oncology benefits for essential protection
- Vital Cover Plus (R180/month) – 700% coverage with in-network co-payments and sub-limit benefits
- Super Cover Plus (R360/month) – 700% coverage plus out-of-network co-payments, scan coverage, oncology extender, and maternity benefits
- Absolute Cover Plus (R620/month) – Premium 700% coverage with unlimited benefits, ambulance services, comprehensive oncology protection, and the highest limits
All plans include TRA Assist (trauma counselling, panic button, home drive) and complimentary travel insurance. No general waiting period.
