So last year you exhausted your medical aid by June. This year you upgraded, it’s costing double, and they still aren’t paying. What’s going on?

It’s called the self-payment gap – it’s usually only found on the more expensive plans – and it creates the most confusion.

Take me for example.
I spend just over R2, 000 a month – or R25, 000 a year – on medical aid.

The question I ask is: “So how much of that goes towards doctors, dentists, and medicines?
The princely sum of R3, 750! Two visits to the dentist, one annual checkup at the doctor, one bout of flu, and poof – it’s gone by June.

From July to December I end up paying everything out of pocket. My self-payment gap can be very big or very small depending on my health. It’ a chance I’m willing to take.

Spare a thought for the couple with three kids this winter.

Last year they looked at two options:

  1. A less comprehensive but more affordable plan with a medical savings account but no emergency parachute, and
  2. A more comprehensive, more expensive plan and a medical savings account with an emergency parachute

So my question to you is: “Would you jump out of a plane with a dodgy parachute and no emergency?

Chances are no, and they weren’t either, so they chose the more expensive option. To put this in perspective it meant that they went from spending R7, 000 a month on medical aid, to R10, 000 a month.

When you’re spending that kind of money you expect your bills to be taken care of, right?

The upgraded plan worked something like this:

  • A healthy medical savings account for things like doctors, dentists, and medicines – up from R20, 000 the previous year to R30, 000 this year!
  • A small self-payment gap of R5, 000 which was for their pocket, and
  • An unlimited expense account after they got through the gap

But it wasn’t all as rosy as they thought.
Halfway through the year, and the medical savings account is out the window. They’re in the self-payment gap – they’ve spent R6, 000 – but the gap isn’t closing.

3 reasons why the self-payment gap hasn’t closed

They weren’t submitting all their medical bills while in the self-payment gap

Each time hubby paid for medicine, he threw the invoice in the trash can. The medical aid was unaware of the expense, so the gap stayed the same. You can imagine the intense discussion which took place once his wife found out about this.

They’re paying for name brands

Offered a choice between name brands and generics, the wife chooses name brand every time. Problem is, the scheme might only take the cost of the generic option into account, or in some cases, not at all.
So imagine the brand name costs R100 and the generic R80. While the scheme will pay the R100 if there’s money available in their account, the R100 – or the difference of R20 between the two – could get added to the self-payment gap.

By the way, this applies to over-the-counter medication as well.
Over-the-counter means medicines which can be bought without a prescription. It really gets tricky when the doctor includes non-prescription medicines along with prescription medicines on his script.

Their doctor is overcharging

Every scheme has what’s called a health rate. This is what they’re willing to pay for a medical procedure. So take doctors for example. The scheme might have decided on a health rate of R350 per consultation. What if the doctor charges R400 a consultation?

Once again the scheme will pay the R400 while there’s money in the medical savings account, but the R50 difference gets added to the self-payment gap.

So there you have it. Each scheme is different, so I’d recommend you speak to them about this.

Is the unlimited above threshold benefit really unlimited?

Yes, the scheme will pay for unlimited medical expenses, BUT only at the health rate for that expense. You might find yourself making co-payments once there.

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  1. yep I do agree, same thing happened to me , Medical Aid rates go up and from July to December I pay out of pocket for medicines because they only give a savings of 6000 rand.

  2. My telephonic experience with discovery is not good at all it feel like they look for every excuse in the book not to help me – we have a group and register a designated person on the group form but every time that person want to do enquiries it is a problem – they dont have on their screen etc and you can just not get answers

    the reference numbers for discovery on the bank statements is also meaning nothing to an employer as you cannot identify whos medical aid debitorder it is as the medical aid no is not used in reference and when you phone discovery with bankref no they can also not help you. the correct identifyable no is needed to use on ba nk statement for debitorders and monies received. This will make life easier on the customer as well as discovery query agents – and will cancel out a lot of enquiries and save both time and frustration

    • Hi Corlia,

      It can be very frustrating I know. What you need to do is build up a relationship with your group billing specialist versus using the call centre.
      Another person to pull in (before you pull your hair out) is your health broker when you’re having issues as you’ve mentioned.

  3. Do you know if there’s some sort of insurance to assist when you’ve reached self payment gap? I found a lot of places that cover the difference between scheme rates and what doctors charge, but nothing for self payment gap in particular.

    • Hi Elana,

      No insurer covers the self payment gap.
      Self-payment gap is related to your day-to-day medical expenses (which is under your control) and not your hospital benefit (which is out of your control since what the surgeon charges is out of your hands).