Rising healthcare costs have made many South Africans nervous. Specialist fees, stories of unexpected co-payments, and complex medical jargon have pushed thousands of people towards gap cover — often without fully understanding whether they actually need it.

Speaking on HOT Business with Jeremy Maggs, powered by Standard Bank, Profmed CEO Craig Comrie suggests that this anxiety may be misplaced for most medical scheme members.

“Many people believe there’s a big gap, without realising how much medical schemes already pay.”

According to Comrie, the real pressure point in the system is not medical schemes — but a shortage of specialists. South Africa has far fewer specialists than international standards recommend, which means longer waiting times and higher fees due to simple supply and demand. To compensate, medical schemes have steadily increased how much they reimburse specialists, often paying close to 200% of scheme rates.

The problem? Many consumers don’t realise this.

“About 95% of specialists charge within what medical schemes already fund.”

This misunderstanding has helped fuel the rapid growth of gap cover products. While gap cover does have a place — particularly for the small percentage of doctors who charge well above scheme rates — Comrie warns that these products are insurance-based and profit-driven, unlike medical schemes, which operate for members’ benefit.

In some cases, simply having gap cover can even lead to higher bills.

“A tonsillectomy is a tonsillectomy — regardless of the cover you have.”

So what’s the smarter strategy? Instead of automatically adding gap cover, Comrie advises consumers to review their medical scheme option first. Many people pay hundreds of rand a month for gap cover while remaining on the lowest scheme option — when upgrading their scheme could offer broader protection, plus better dental and optical benefits.

His advice is simple: ask questions, review your claims history, and reassess regularly.

If you’ve paid for gap cover for years without using it, it may be time to rethink whether it truly forms part of your healthcare strategy.

Listen to the full interview on HOT Business below: