Surgeons and medical staff working together during a complex surgical procedure in a modern hospital.
By Brian Harris, CEO, Turnberry Management Risk Solutions
Medical aid remains essential for accessing private healthcare in South Africa, but many members are surprised to discover that it does not always cover the full cost of treatment. While regulations such as Prescribed Minimum Benefits (PMBs) ensure access to a defined level of care for certain conditions, medical schemes continue to apply tariff limits, treatment protocols, co-payments and other funding rules that can leave members responsible for significant out-of-pocket expenses.
As healthcare costs continue to rise and funding models evolve, understanding where these shortfalls occur is becoming increasingly important for consumers. It is also driving greater awareness of supplementary products, such as gap cover, that can help reduce the financial impact of unexpected medical expenses.
Understanding the limits of medical aid
PMBs were introduced to ensure that all medical scheme members have access to treatment for a defined list of emergency, chronic and life-threatening conditions. However, there is a common misconception that PMBs guarantee unlimited funding for every treatment option.
In practice, PMB cover remains subject to scheme rules, treatment protocols, formularies and designated service provider (DSP) requirements. In many cases, funding is aligned with the level of care that would ordinarily be available in the public healthcare system. This is particularly relevant in specialised areas such as oncology, where newer or more advanced treatments may not always be fully funded.
As a result, patients may still face co-payments, sub-limits or medical expense shortfalls, even when the underlying condition qualifies as a PMB.
Why medical expense shortfalls occur
PMBs are only one part of the broader healthcare funding landscape. Even when treatment is approved, medical schemes reimburse healthcare providers according to their own tariffs and benefit structures, while specialists and hospitals may charge rates that exceed these limits.
The difference between what a provider charges and what a medical scheme pays becomes the member’s responsibility.
Medical schemes also rely on measures such as co-payments, benefit limits, designated service providers and pre-authorisation requirements to help manage rising healthcare costs and maintain affordable contributions. Where these requirements are not met, members may be required to contribute towards their treatment costs.
For many South Africans, this means that having medical aid does not necessarily eliminate the risk of unexpected medical bills.
Helping consumers navigate a complex system
As healthcare funding becomes increasingly complex, consumers need a clearer understanding of how their medical scheme works and where potential shortfalls may arise.
Many members only become aware of funding limitations once they receive an unexpected account after treatment. Greater awareness of scheme rules, tariffs, PMBs and DSP requirements can help individuals make more informed healthcare decisions and better prepare for possible out-of-pocket expenses.
Financial advisers and healthcare consultants also play an important role in helping clients understand how their cover works and ensuring they regularly review their healthcare needs as medical schemes update benefits and funding rules.
Planning for the future
Healthcare funding should not be viewed as a once-off decision. Medical scheme benefits, pricing structures and healthcare costs continue to evolve, making regular reviews an important part of long-term financial planning.
For many households, understanding where medical expense shortfalls may occur—and whether supplementary cover such as gap cover is appropriate for their circumstances—has become an increasingly important consideration.
As regulation continues to shape South Africa’s healthcare landscape, consumers will need to make informed decisions about how they protect themselves against rising medical costs. While no single solution eliminates every healthcare expense, a clear understanding of medical scheme benefits, funding limits and available options can help reduce the financial impact of unexpected treatment.
Brian Harris is CEO of Turnberry Management Risk Solutions. Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP No. 36571). Products are underwritten by Lombard Insurance Company, an authorised Financial Services Provider (FSP No. 1596) and insurer conducting non-life insurance business.