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Your medical aid paid the claim. So why are you still getting a bill?

It is one of the more frustrating surprises in private healthcare.

You go into hospital. You have medical aid. The procedure is authorised. Everything seems covered.

Then, a few weeks later, another account arrives.

R3 500. R8 000. R20 000. Sometimes much more.

The reason is simple: having medical aid does not necessarily mean that every healthcare provider will charge the same rate that your medical scheme is prepared to pay.

That is where gap cover can become an important part of your overall healthcare protection.

But gap cover is often confused with health insurance. They are not the same thing.

First: what is gap cover?

Gap cover is an insurance product designed to complement your medical scheme membership.

In South Africa, gap cover is specifically structured around medical expense shortfalls and requires the insured person to belong to a medical scheme. It is not a medical aid and cannot replace medical scheme membership.

Think of it this way:

Medical aid pays first. Gap cover may help with certain qualifying shortfalls afterwards.

For example, your medical scheme may reimburse a specialist according to the scheme tariff, while the specialist charges more than that amount.

Depending on your gap-cover policy, it may help cover some or all of that difference, subject to the policy’s limits, exclusions and terms.

Some gap-cover products may also provide benefits for specified co-payments, deductibles or other defined medical-expense shortfalls.

The important word is specified. Gap cover is not a blank cheque for every amount your medical scheme does not pay.

Why has gap cover become so important?

Private healthcare costs can be difficult to predict.

Even when you have selected a medical aid option carefully, you could still encounter circumstances where the amount charged and the amount paid by your medical scheme are different.

And these shortfalls tend to arrive at exactly the wrong time — when you are recovering from surgery, dealing with a diagnosis or looking after a family member.

A relatively affordable monthly premium for gap cover can therefore provide an additional layer of financial protection against certain unexpected healthcare expenses.

It is less about buying “more medical aid” and more about protecting the space between what your medical scheme pays and what you may still owe.

So what is health insurance?

Health insurance works differently.

Depending on the policy, health insurance typically pays a defined benefit when a specified health event occurs.

For example, a policy could pay a fixed amount following a particular event or provide a stated daily or lump-sum benefit.

The Council for Medical Schemes explains that these policies generally pay benefits according to specific insured events and are different from the way a medical scheme funds healthcare benefits.

This distinction matters.

A medical scheme operates under the Medical Schemes Act and is required to provide benefits such as Prescribed Minimum Benefits in accordance with the applicable rules and legislation.

Health insurance operates within the insurance regulatory framework and does not carry the same obligations as a registered medical scheme. The regulatory framework deliberately distinguishes between insurance products and medical scheme business.

Medical aid vs gap cover vs health insurance

Here is the simplest way to think about it:

An example

Imagine you require surgery.

Your medical scheme approves the hospital admission.

The specialist charges R30 000, but your medical scheme reimburses R20 000 according to the benefits and tariff applicable to your option.

That potentially leaves you with a:

R10 000 shortfall.

If you have suitable gap cover and the claim qualifies under your policy, the gap-cover insurer may help cover that shortfall.

Without it, that R10 000 may become your responsibility.

Health insurance, by comparison, does not simply “fill that R10 000 gap”. Its payment would depend on whether the particular event is covered and what benefit the policy provides.

Before buying gap cover, ask these questions

Do not choose gap cover based on price alone.

Ask your financial adviser:

• Which medical expense shortfalls does the policy cover?
• How much above the medical scheme tariff can it cover?
• Which co-payments or deductibles are included?
• Are there exclusions for particular procedures or treatments?
• Are there waiting periods?
• What are the annual limits?
• Does the cover apply to everyone on my medical scheme membership?
• How does the policy work with my specific medical scheme and option?

Gap-cover policies can differ significantly, so the wording of the policy matters.

Your medical aid choice and gap cover should work together

This is where advice becomes particularly valuable.

Choosing healthcare cover should not be about buying three unrelated products and hoping they somehow fit together.

Your medical scheme option, hospital network, savings benefits, co-payments, gap cover and overall household budget should be considered together.

In some cases, changing your medical aid option could alter the gaps you are exposed to. In others, appropriate gap cover could provide useful additional protection without moving to a significantly more expensive medical scheme option.

There is no single solution that is right for everyone.

The goal is not simply to have more cover.

It is to understand where your financial risks are — and make sure the different pieces of your healthcare cover work together.

Speak to a Universal Cover adviser

Before joining, upgrading, downgrading or changing your healthcare cover, speak to an adviser who can help you compare the options properly.

At Universal Cover, we can help you understand the difference between medical aid, gap cover and health insurance — in plain language — so that you can make an informed decision for yourself and your family.

Because the worst time to discover a gap in your healthcare cover is when the bill has already arrived.

Terms, conditions, exclusions, waiting periods and benefit limits apply to insurance products. Medical scheme benefits are subject to the registered rules of the relevant scheme. Always review the applicable policy and scheme documentation before making a decision.