As South Africa enters the medical aid open season, millions of consumers are reviewing their healthcare options — but many may be shocked to learn their medical aid doesn’t stretch as far as they think. Rising medical inflation, specialist fees well above scheme rates, and new co-payment structures mean that even top-tier plans can leave members out of pocket.

“People assume that a 100% cover plan means full protection,” says Brian Harris, General Manager of Operations at Turnberry Management Risk Solutions. “But specialists can charge three, four, or even five times the medical aid tariff — leaving patients with hefty shortfalls.”

These shortfalls are no longer rare or confined to luxury treatments. Everyday procedures — from maternity care and gastrointestinal scopes to orthopaedic surgeries — often come with unexpected costs. Harris notes that Turnberry has paid out more than R200,000 to hundreds of clients in recent years, with many unaware of the financial gap until the bill arrived.

So why are these shortfalls growing? Harris points to two key factors: the rising cost of advanced medical technology, and the balancing act medical aids face between affordability and coverage.

“It’s a complex environment,” he says. “There are over 100 medical aid options and more than 40 gap cover providers — and navigating that without expert advice is difficult.”

Gap cover, once considered an optional extra, is fast becoming essential. It’s designed to bridge the space between what your medical aid pays and what your specialist charges — and could save families hundreds of thousands of rands.

As Harris puts it, “It’s one of those things you only realise you need after it’s too late.”

Listen to the full interview on HOT Business with Jeremy Maggs below: