A common misconception is that a 100% medical scheme option will pay for 100% of a members in hospital treatment costs.

This is simply not the case.

The percentages used by medical schemes describe the percentage of the medical schemes own tariff list they will pay and are not an indication of the percentage of the treatment costs that they would cover.

Medical practitioners such as Doctors, Surgeons and Specialists are free to charge what they choose and they may even charge up to 400% of the medical schemes allocated contribution. The result is a payment shortfall or Gap that is for the account of the medical scheme member. These payment Gaps can be significant. For example members that are on a 100% medical scheme option would be liable for a personal payment of approximately R10 000 should they undergo a caesarean childbirth, a coronary bypass operation would leave a shortfall of approximately R29 000, hip replacement R18 000, knee replacement R14 000 and tonsillectomy R5 500. These are some of the frequent shortfalls that exist but in total there are thousands of procedures that would result in payment shortfalls. It is specifically these payment shortfalls that are designed to be covered by Medical Gap Cover. Medical Gap Cover covers the difference between the medical scheme tariff and the medical practitioners charge up to 400% of the medical scheme tariff.

For a premium of R140 per month, cover is provided with a total annual limit of R200,000 per individual member and R2m per family.