100% of the Medical Aid Rate – What does it mean for you and are you covered?

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100% of Medical Aid Rate – What does it mean for you and are you covered?

You are a member of a Medical Scheme to protect you and your family – great! Should you not have a Medical Scheme, read ‘Why do you need Medical Aid?’ here.

There are many Medical Schemes on the market that cover you at “100% Medical Aid Rate”. Although covered at 100% Medical Aid Rate may give you the impression that you are fully covered, we would like to highlight what this truly means for you.

Medical Schemes which cover claims at 100% Medical Aid Rate often only cover a small portion of claims – this is because many specialists can charge significantly higher rates than the Medical Aid Rate.


Let’s look at this example

Bob, who chose a simple hospital plan even though he now requires frequent prescribed medication, has unfortunately fallen quite ill and needs to be hospitalised to undergo a specialist procedure. He contacts the call centre of his Medical Scheme and obtains authorisation for his procedure at an associated hospital. The call centre agent reminds him that he is covered at 100% Medical Aid Rate for the specialists who are conducting Bob’s procedure. Bob thinks this is great as apparently the procedure is very expensive.

Two weeks after his procedure, Bob he receives the invoices from the two specialists, one being an anesthetist. Bob contacts the specialists’ offices and enquires as to the reason he has received the invoices as his Medical Scheme provider authorised the procedure that covered him at 100% Medical Aid Rate. The administrative staff explain to Bob that although his Medical Scheme covers him at 100% Medical Aid Rate, the specialists charge 300% and 400% respectively above the Medical Aid Rate.

Visibly annoyed and dismayed, Bob is liable for two very expensive invoices (the 200% and 300% outstanding) and needs to borrow money from his parents.


A Medical Aid Scheme which covers your claims at 100% of the Medical Aid Rate does not always mean that you will not have to pay. Specialists often charge more than 100% of the Medical Aid Rate and will hold patients personally liable for the unpaid shortfalls. Speak to us today and enquire about our excellent gap products that will help you avoid this pitfall.

Ensuring you are on the right Medical Scheme is just as important as ensuring you are on a Medical Scheme. The consequences of an ill-fitting scheme can have devastating financial consequences.


Would you like help in how best to have your Medical Scheme structured to your needs? Contact Quattro Med or fill out the form below.




If you missed these articles, click to read more

‘Why do you need Medical Aid?’ Read it here

‘What is Gap Cover? How Does It Work and Why Do You Need It?’ Read it here

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