Cape Business News – 5th December 2025
As the year draws to a close, many people take the opportunity to reassess whether their medical aid still fits their needs and budget. Plans change, benefits shift and co-payments often increase. At the same time, life circumstances evolve: families grow, health needs change and financial priorities shift. In the current environment, medical aid alone increasingly leaves gaps. Specialist fees frequently exceed scheme rates, penalties for using non-Designated Service Provider (DSP) hospitals are becoming common, and co-payments can be significant, particularly after a downgrade. That is why reviewing gap cover at the same time as your medical aid is essential. Gap cover cushions you from unexpected medical expenses and helps ensure that a medical event does not become a financial shock.
Why medical aid falls short and what gap cover does about it
Medical schemes face rising healthcare costs but are limited by the Council for Medical Schemes in how much they can increase contributions. To remain viable and competitive, they have been forced to introduce higher co-payments, stricter network rules and more sub-limits. This cost-sharing approach means members fund a greater share of care themselves, especially when specialist fees are well above scheme tariffs or treatment occurs outside designated networks.
Even on top-tier plans, shortfalls are a reality, and a single hospital admission – particularly for orthopaedic procedures or oncology, once limits are reached or treatment is at a non-DSP facility – can result in substantial out-of-pocket costs.
Gap cover exists to bridge these exposures, covering shortfalls and co-payments and helping protect your finances when you need care. It is important to remember that it supports, rather than replaces, medical aid. If your medical scheme does not cover a particular treatment category, gap cover generally cannot step in. This makes it critical to align the two and review them together.
Aligning cover as needs and plans change
Most schemes only allow upgrades during the annual change window, while downgrades are usually possible at any time. If you are adjusting your medical aid, whether to manage affordability or to secure more comprehensive care, your gap cover should be reviewed in tandem.
Downgrading often increases co-payments and limits, so your gap cover may need to be strengthened to maintain the same level of protection. Likewise, changes in your health profile or family circumstances may require a different balance between medical aid and gap benefits. Working with a broker can simplify this process. Their expert advice comes at no additional cost to you and ensures that both products fit your needs and work seamlessly together.
Peace of mind through proper protection
Shortfalls are no longer the exception: they are now a consistent feature of private healthcare. Reviewing your medical aid and gap cover together each year ensures your financial protection keeps pace with rising medical costs and changing benefit structures. By treating these products as a pair, staying alert to scheme updates and making sure that your gap policy matches your chosen plan, you can remain confident that your health needs and your budget are equally protected.
The right combination of medical aid and gap cover provides the reassurance that, if you need treatment, the focus remains on your recovery rather than on how to fund it. Speak to your broker or financial advisor to ensure your cover fits your requirements.
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