28 Aug The 500% reality: What your doctor charges vs. what your scheme pays
“You’ve got medical aid, so you’re covered… right?” That’s what most people believe, until the hospital bill arrives. The shock? It’s thousands more than you expected, and your medical aid isn’t covering it.
This is the harsh reality of South African private healthcare: medical aid alone often isn’t enough. If you don’t have shortfall protection, you could be paying the difference out of your own pocket.
What is MST and why it matters
The Medical Scheme Tariff (MST) is the benchmark rate your medical aid uses to decide how much it will pay for procedures and consultations.
Here’s the catch:
- Most medical aids pay 100% of MST.
- A few comprehensive plans stretch to 200% of MST.
- Many private specialists charge well over 500% of MST.
This gap is where the problem lies and why so many people are blindsided by hospital bills.
Visual example:
- Specialist fee: R10,000
- Medical aid (100% MST) pays: R2,000
- You owe: R8,000
The 500% reality in action
Shortfalls can hit you hard in situations like:
- Maternity care and C-sections
- Specialist procedures like scopes or MRIs
- Emergency surgeries
- Oncology treatments
That unpaid amount? It’s your savings, your holiday fund, your financial safety net, gone in one medical bill.
How GapCover plans bridge the gap
GapCover exists to protect you from these medical shortfalls.
- GapCover Primary: Covers up to 300% of MST | from R130/month
- GapCover Elite: Covers up to 500% of MST | from R220/month
- GapCover: Covers up to 500% of MST | from R234/month
- GapCover Combined: Covers up to 500% of MST | from R318/month
All plans offer up to R198,660 per beneficiary, per year, covering the in-hospital and specialist shortfalls that medical aid doesn’t.
Who needs GapCover?
- Young professionals who consult private specialists
- Women planning for maternity or elective surgery
- Families with dependants on medical aid
- Anyone whose scheme pays only 100% or 200% of MST
If you fit into one of these groups, GapCover can save you from unexpected and unaffordable medical bills.
What to do next
- Check your medical aid statement to see your MST payout rate.
- Compare it to what private specialists charge.
- Choose a GapCover plan that protects you against the difference.
Bottom line: Medical aid is essential, but it’s not enough. Without shortfall protection, you’re exposed to thousands in out-of-pocket costs. GapCover bridges the gap, giving you peace of mind when you need it most.
Protect your health today. Discover more at gapcover.co.za
Disclaimer: GapCover is not a medical scheme, and the cover is not the same as that of a medical scheme. Membership is not a substitute for a medical scheme membership. Terms and Conditions Apply.