Medical aid has long been considered a safety net against the cost of private healthcare in South Africa, but as brokers and financial advisers know all too well, even top-tier medical aid plans come with unwelcome medical expense shortfalls. Clients are increasingly confronted with unwelcome medical expense shortfalls; from sudden co-payment for a procedure or shortfalls for specialists after surgery, putting their financial stability at risk.
As a broker, it’s critical to help your clients understand that medical aid alone does not guarantee full financial protection. Everyday medical procedures and advanced treatments alike are triggering rising out-of-pocket expenses. As medical inflation continues to outpace salary growth and scheme benefit increases, these shortfalls are only set to increase, making gap cover an essential part of any holistic medical risk strategy.
Why are medical expense shortfalls becoming more common?
Medical schemes operate within set guidelines, however, many specialists charge significantly more than these rates – sometimes up to 500% of the medical scheme rate, depending on the doctor and the procedure. Most medical aid plans will cover 100% or 200% of the scheme rate, depending on the plan. This creates significant shortfalls, and the patient is responsible for the unpaid balance.
These shortfalls are becoming increasingly common, not only because specialists are charging more for their services. Medical inflation is rising much faster than the Consumer Price Index (CPI), meaning the cost of treatment is increasing faster than clients’ income growth. The Council for Medical Schemes (CMS) also governs and limits medical scheme premium increases. This means that medical schemes have been forced to introduce co-payments and sub-limits to certain treatments and protocols in order to keep premiums as affordable as possible. The result: clients are bearing more of the burden.
The growing financial burden on clients
Gap cover is designed to address this exact issue, helping to reduce the gap between what medical schemes pays and what providers charge. It typically covers in-hospital tariff shortfalls, co-payments, and other exclusions for listed procedures. For brokers, it’s an essential product to include in financial planning conversations.
Consider the real-world impact. One Turnberry client faced R678,000 in shortfalls while receiving treatment for a malignant ureter tumour, spanning a total of 44 claims, all of which were covered by their gap cover policy. Another, with 27 claims spanning autoimmune, gastrointestinal, and spinal issues, claimed R478,085.04, again largely due to specialist charges that exceeded scheme rates. It’s important to note that these claims occurred over a four-year period and remained within the Overall Annual Limit (OAL), which sets a cap on the total amount that can be paid out each year. This highlights how gap cover, when used consistently and within policy limits, can offer long-term financial relief for ongoing medical needs.
Gap cover is relevant to all life stages
Gap cover is not just for catastrophic events or for older people. Routine procedures like scopes, sinus surgeries, maternity-related costs, or minor surgical interventions often result in shortfalls. These are common among younger and healthier individuals too. As a broker, it is important to dispel the myth that gap cover is only for catastrophic events or older clients. Everyone is at risk—making gap cover a necessary buffer for clients across all life stages.
Your advisory role matters
As a financial adviser, you are uniquely positioned to assess your clients’ medical aid plans and recommend gap cover products that suit their needs. Whether explaining the difference between co-payment cover and tariff shortfalls, or guiding them through policy limits, your expertise helps ensure clients are financially protected.
With healthcare costs continuing to rise and medical schemes struggling to keep pace, medical aid alone no longer provides sufficient protection. Gap cover is no longer optional—it’s essential. Including it in your advisory conversations helps protect your clients from financial strain and positions you as a trusted, forward-thinking partner.
Now is the time to encourage your clients to review their healthcare risk cover and explore tailored gap cover solutions. When medical aid falls short, your guidance shouldn’t.
Brian Harris, GM Operations, Turnberry Management Risk Solutions
Lifestyle and Tech – 11th November 2025
Why brokers should be talking to clients about gap cover now more than ever – Lifestyle & Tech
Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571). Underwritten by Lombard Insurance Company, an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.
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