Medical Shortfall Problems for South Africans

What are South Africa’s medical shortfall problems?

  • South Africa’s medical aid schemes are under financial pressure
  • Medical aid members must subsidise every medical shortfall
  • Gap cover provides the solution
  • Gap cover is becoming increasingly popular
  • The medical scheme industry is at a crossroads

The South African medical aid industry is at a crossroads.

It is caught between:

  • Growing dissatisfaction of members who have to subsidise the shortfalls. The gap is between what medical schemes pay for treatment and what medical professionals charge for their services; and
  • Increasing financial strain in lost revenue. That is because more and more people opt for basic medical aid. Instead they supplement their health care package with gap cover insurance

Medical schemes under pressure

A further strain on the medical scheme industry is a South African Council for Medical Schemes’ ruling.  The ruling says that medical aid members receive full cover for Prescribed Minimum Benefits (PMBs).

These PMBs include nearly 200 medical conditions and 27 chronic conditions, as well as the inclusion of Medical Shortfallcertain cancer treatments and medical emergencies.

All of these factors have created significant challenges.

Medical schemes are under increasing financial strain to provide both funding and delivery of quality health care.

Growing dissatisfaction

This, in turn, has led to growing dissatisfaction by medical scheme members who feel short-changed.

They want to know why they have to pay high monthly premiums when their medical schemes fail to pay 100% of the cost of their medical treatment.

Consumers also want to know why they are responsible for the medical shortfall between what their medical schemes pay and what the medical profession charges for its services.

Medical scheme tariff ceilings

It is an unfortunate fact of life that all South African medical schemes limit their cover with what is known as the Medical Scheme Tariff (MST).

The tariff ceilings imposed by medical schemes are more often than not way below what medical professionals charge for their services.

In fact, in most cases, the medical profession charges up to 500% more than medical scheme tariff ceilings, leaving substantial shortfalls for medical aid members to pay.

Gap cover growing in popularity

This phenomenon has heralded the emergence of medical gap cover insurance.

Offered to members of medical schemes, gap cover is an affordable additional product that covers the gap between medical scheme tariffs and bills from members of the medical profession.

Who are gap cover providers?

South Africa has a large number of gap cover providers, including well-known industry leaders such as:

  • Discovery Health
  • Zestlife
  • Stratum
  • Complimed
  • Old Mutual

An online search will reveal that gap cover policies can be obtained for the whole family for as little as R118 a month.

What exactly is medical shortfall cover?

Essentially, gap cover is:

  • An insurance policy that covers the shortfall between medical scheme tariff ceilings and charges imposed by members of the medical profession
  • It is an affordable and essential health care product
  • Gap cover is for members of a registered medical aid scheme


With the high cost of living, many South Africans are unable to meet their monthly expenses.

However, medical aid and gap cover is a vital and necessary expense to protect families against the exorbitant costs of medical care.

Consumers are urged to seek advice from a qualified broker or financial advisor before purchasing health care products or changing existing portfolios.

Start your journey to medical security – request a gap cover on this page.

All info was correct at time of publishing