Medical aid pays according the rates as laid out in the National Health Reference Price List (NHRPL). Disruptions with the annual publishing of the list in recent years has led to schemes applying an inflation-linked increase to tariffs. However, the rates a medical aid pay may not match what a service providers demands. In other words your doctor may charge more than the medical aid tariffs and has the legal right to do so.

Find cover that suits your budget

Furthermore, some plans do not cover certain procedures in full. It means the member is faced with a shortfall in the medical aid reimbursement and the difference has to be paid out of his/her own pocket. Often medical aid members do not know that these short payments will arise until they get the bill after the procedure is done. Fortunately medical gap cover provides the financial protection against these shortfalls and co-payments by medical aids.

Why do medical aids not pay in full?

There are several reasons why your medical aid not pay a bill in full:

  1. The service provider (practitioner or hospital) may have charged rates that are higher than the medical aid rates (NHRPL + inflation-linked increases).
  2. The specific medical aid plan does not have a full benefit for the procedure that has been conducted.
  3. There are insufficient funds available due to annual limits having been reached.
  4. The procedure was not deemed emergency/necessary but the practitioner feels it should be done as part of further investigation.

Common Reasons

The first and last reasons have become common issues in recent years. Many practitioners have opted to charge private rates that are not in accordance with the medical aid rates. Initially it was medical specialists who were pricing themselves higher. These days other practitioners have also followed suit.

Many practitioners have now opted to contract out of medical aid meaning that patients are forced to pay cash for treatments and then claim back later, often not getting reimbursed in full. Co-payments have become a common issue in the private healthcare sector within South Africa.

Medical aids have also been ‘tightening their belts’ in the face of rising healthcare costs and at times over servicing on the part of practitioners. One such case is seen with MRI (magnetic resonance imaging) scans and certain endoscopic procedures (upper GI endoscopy, colonoscopy and so on).

A medical aid may only pay 50% of the bill for these procedures if it is not immediately evident that the procedure is necessary. If there are significant findings meaning that the scan or scope was warranted then the medical aid will pay for it in full. If not, patients have to pay the remaining 50% co-payment.

Member’s Responsibility

Medical aid members are responsible for any shortfall in payment on the part of their medical aid. Many South Africans are under the impression that a medical scheme is entirely responsible for all their healthcare bills throughout the year, or for as long as they are paying their premiums (monthly contributions). This is untrue.

Medical aid, like an financial cover, is there as a safety net to absorb the financial impact of medical care when it is most needed. At the end of the day the contract is between the medical aid and member, not between the medical aid and doctor. While some doctors who are contracted into medical aid will claim and be paid directly, the doctor cannot be negotiating the short payment on the part of the patient’s medical aid.

It is the patient or main member’s responsibility to resolve these problems with their medical aid. At the end of the day, the patient/member has to pay for the short payment if the medical aid will not pay in full. Co-payments for patients and short payments by medical aid have become so common these days that medical gap cover has become essential.

This is a short term insurance policy for medical aid members. Gap cover pays for the difference between what the doctor charges and medical aid pays. However, the short payment is only applicable for hospital-related bills. Out-of-hospital co-payments are not covered by medical gap cover and have be settled in cash by the patient or medical aid member.

Signed Consent for Higher Fees

The issue of co-payment was affecting consumers to such a degree that regulations were put in place to minimise the shock of being landed with a bill after treatment. Practitioners are now required to inform patients that they charge above medical aid rates and that they will be responsible for the short payment.

Patients who refuse to accept these terms and sign the consent form can instead seek treatment at another practitioner who is more affordable. While it does not regulate the current pricing issues by medical professionals, the signed consent at least informs patients of the costs they will face after their medical aid pays the bill, at least in part.


  1. Motsoaledi wants co-payments abolished.
Tagged on: