5 medical scheme myths that could cost you thousands

South Africa’s healthcare system is split between public and private sectors, with medical schemes designed to act as a financial safety net. But for millions of members, that safety net is misunderstood. Many assume they’re fully protected from surprise costs only to discover the truth during a health crisis.

“We see too many families caught off guard by medical shortfalls they thought were covered. The right advice, the right plan, and the right partner can make all the difference.” Justine Koekemoer, executive: employee benefits at ASI Financial Services

And the stakes are rising. With premiums climbing, benefits becoming more complex, and the National Health Insurance (‘NHI’) roll out on the horizon, it’s never been more important to understand what your cover really includes and what it doesn’t.

Here are five common myths that could leave you out of pocket, and what you can do to protect yourself.

Myth 1: 'I’m healthy, so I don’t need much cover, I’d rather save the money'

It’s tempting to think that if you’re young, fit, or rarely get sick, you can get by with minimal cover or none at all. But good health today doesn’t guarantee protection tomorrow.

Private healthcare in South Africa is expensive. A single hospital stay, surgery, or ICU admission can cost tens or even hundreds of thousands of rands. Public hospitals are available, but they’re often overcrowded and under-resourced.

And here’s the truth: your health can change in an instant. Accidents, sudden illnesses, or unexpected diagnoses don’t wait for your finances to catch up.

The financial fallout: Minimal cover might not include specialist fees, scans, or post-hospital care. You could face massive co-payments or be forced to rely on public hospitals when you need urgent private care.

Smart move: If full cover isn’t in your budget, don’t go without. A hospital plan paired with a suitable gap cover can offer meaningful protection. Gap cover helps bridge the difference between what your scheme pays and what providers charge, shielding you from painful financial surprises.

Myth 2: 'My medical scheme covers everything, I won’t have to pay extra'

This is one of the most common and costly misconceptions.

Even “100% cover” doesn’t mean your scheme pays 100% of your actual medical bill. It means they pay 100% of the medical scheme tariff which is often far less than what specialists charge as Specialists have the ability to determine what rate they charge (not regulated) Many benefits also come with sub-limits, exclusions, or waiting periods.

Hospital admission might be covered, but what about pre-admission tests, follow-up consultations, or out-of-network providers? These can all come with unexpected costs.

The financial fallout: If your specialist charges 300% of the scheme tariff and your plan only covers 100%, you’re liable for the remaining 200%. That’s a serious financial hit.

Smart move:

• Read your benefit schedule carefully
• Ask your provider for a quote before any planned procedure
• Check if your provider charges above tariff
• Consider gap cover to protect against shortfalls
• Monitor your medical savings account and use it wisely

Myth 3: 'If I have a good medical scheme plan, I don’t need gap cover'

Even the best medical scheme plans have limits. That’s where gap cover comes in.

Gap cover exists because medical schemes don’t always pay the full cost of treatment. Many specialists charge well above scheme tariffs, and even “comprehensive” plans can leave you with a hefty bill.

Gap cover helps bridge the gap but it’s not a silver bullet. It typically only applies to hospital-related shortfalls and doesn’t cover day-to-day expenses like GP visits or dental work.

The financial fallout: Without gap cover, you could be left with a bill of hundreds of thousands of rand after a hospital stay. Even with gap cover, if your provider charges more than the cover limit, you’ll still owe the difference.

Smart move:

• Understand your scheme’s tariff structure
• Know what your gap cover includes - and what it doesn’t
• Ask your provider about their rates before treatment
• Budget for worst-case scenarios, not just the expected

Myth 4: 'Downgrading or sticking with my old plan is harmless, I’ll deal with it later'

Medical scheme cover isn’t a “set it and forget it” product. Your needs change and so should your cover.

If you’re on a plan that no longer suits your health or lifestyle, you could be overpaying for benefits you don’t use or underinsured when you need them most. On the flip side, downgrading to save money without understanding the trade-offs can leave you exposed.

The financial fallout:

• You might be paying for benefits you never use
• Or you might be under-covered when your health changes
• Unused savings may expire or fall short when you need them

Smart move:

• Review your plan annually or at least every two years
• Use the open enrolment window (usually September to December) to make changes
• Ask: “What benefits do I use?” and “What might I need in the next year?”
• Consider whether a hospital plan plus savings and gap cover is a better fit

Myth 5: 'NHI won’t affect me I’ll just wait and see'

The National Health Insurance Act has been signed into law. While implementation will take time, ignoring it could be a costly mistake.

NHI represents a major shift in how healthcare is funded and accessed in South Africa. While the full rollout is still years away, changes are already underway. Medical schemes may eventually be limited in what they can cover, and the regulatory environment is evolving.

Some people think they can cancel their medical scheme now and rely on NHI later but that could leave them without adequate cover during the transition.

The financial fallout:

• Cancelling now could mean massive out-of-pocket costs before NHI is fully operational
• Rejoining later could come with higher premiums or waiting periods
• You may have fewer choices or less flexibility if you delay planning

Smart move:

• Stay informed about NHI developments
• Don’t make decisions based on assumptions speak to a financial adviser
• Plan for the medium term, not just the immediate future

Medical scheme cover myths aren’t just misunderstandings, they’re financial risks. In a system as complex and fast-changing as South Africa’s, staying informed is your best defence.

Take the time to review your cover. Ask the right questions. And if you’re unsure, speak to a trusted adviser who can help you make smart, informed decisions.