Top 10 Gaps in Medical Aid Cover and How to Avoid Them

Most people who have medical aid have experienced a self-payment gap. They land up with a medical bill that their medical scheme will not pay. Here is a list of the 10 most common gaps and how to avoid them.

Top 10 Gaps in Medical Scheme Cover in SA, with Solutions

  1. One of the most common gaps is when you exceed your benefit limit. This means that the claim exceeds the benefit limit of the schemes. Medicals aids have two kinds of limits. These are overall and sub-limits on various kinds of benefits. One example is basic and advanced dentistry.  Solution: To avoid these kinds of gaps, choose a suitable medical scheme for your medical needs.
  2. Sometimes the scheme’s rate is much lower than the doctor’s rate. This possibility is getting more likely in South Africa because there are so few specialists in relation to the population. Solution: Invest in a gap cover policy to cover the gaps and / or make sure you use a doctor who charges within the medical aid’s rate. Your medical scheme will recommend these doctors.
  3. Prescribed medical benefits (PMBs) not covered. Solution: If you have one of the 27 Top 10 Gaps in Medical Aid Gap Coverchronic diseases and nearly 270 other medical conditions, make sure you know your rights and follow the steps required by your medical aid in registering your condition. The law requires that all medical aids provide PMBs.
  4. In some instances a medical aid places a limit on managed care. There are certain protocols that medical aids lay down for the management of many conditions. These range from asthma to cancer. Solution: Obtain pre-authorisation for hospitalisation and care. And supply your medical aid with a “quote letter” from your doctor outlining treatment and prescriptions. This should include the ICD-10 codes. Then find out from your medical aid if all these items are covered.
  5. Medical aids endeavour to control costs by applying co-payments, also called deductibles, to certain procedures and medicines. These are usually procedures or medication that medical schemes believe are not absolutely necessary or effective. These include wisdom teeth removal, gastroscopies and hip replacement.  Solution: find out what your medical scheme’s co-payment list is before signing up.


  1. Cancer patients who belong to medical aids are sometimes alarmed to find that there is a big gap between the cover offered and the cost of cancer treatment. This is because of the increase in the occurrence of the disease. Also treatment costs are much higher. Solution: Find out what level of cancer benefits your medical scheme offers (there are three tiers, with three being the most cover) and adjust your scheme according to your health risk. Consider buying gap cover insurance.
  2. Medical aid members are often faced with inadequate medical savings accounts.  Solution: before this becomes a problem, talk to your broker to ensure that your medical scheme and the associated savings account matches your needs. Also try to place extra funds in the savings account each month. That is to build up reserves in your medical savings account.
  3. Schemes do place limits on body parts (such as hip and knee joints, hearts, etc.) and appliances such as wheelchairs. Your doctor may be able to motivate the medical aid to pay for the most basic of these. However, you will have a hard time persuading your medical aid to pay for a de luxe model. Solution: feed your medical savings account monthly. Do not drain the account, if possible, in the event you need body parts and appliances.
  4. Apart from the common medical cover exclusions such as cosmetic surgery and injuries incurred while doing an extremely dangerous sport, there are some less obvious exclusions, such as the cost of an organ transplant. Solution: make sure you have medical aid cover that makes it possible for you to upgrade to a scheme that includes organ transplant cover should you require it, with a three-month wait before making a claim.
  5. Rehabilitation costs following surgery, a stroke or an accident may or may not be covered by your medical aid. The best medical schemes cover temporary disability. However, it is unlikely that your medical aid will cover several years of rehabilitation. Solution: find out what rehabilitation your medical aid covers, if any. Switch to another medical aid if necessary.

All info was correct at time of publishing