Patients struggle with out-of-pocket medical expenses amid rising doctor fees in South Africa

PATIENTS and financial experts are warning of excessive medical fees as doctors charge up to 500% above medical aid scheme rates. 

They said the out-of-pocket demands for payments are forcing patients on medical aid to take out additional gap cover or risk unaffordable medical expenses. They have accused doctors of turning the healthcare service into an unchecked profit-pursuit industry.

Sanjith Hannuman, a director at AVIB and a financial services consultant, spelled out the extent of the crisis.

“A crisis of trust and affordability is unfolding in South Africa's private healthcare system. Patients, already strained by high medical aid contributions, face a second, devastating financial blow: out-of-pocket payments for services billed at 200%, 300%, or even 500% above medical aid scheme rates. This practice, known as 'balance billing,' has evolved from an occasional nuisance to a systemic feature,” said Hannuman.

Giving an example, Hannuman told the story of a Gauteng man who faced an R85 000 shortfall after emergency spinal surgery, with his specialist having charged 480% of the medical aid rate - a life-altering debt for a life-saving procedure. "These are not anomalies but symptoms of a calculated business model. Where is the open-hearted, patient-centred, loving approach that defines true care? It is being suffocated by a ledger of excess,” Hannuman said.

Hannuman argued that this practice persists because South African law lacks a regulated fee structure for healthcare providers. “Since the National Health Reference Price List (NHRPL) was declared invalid in 2010, providers may charge what they deem appropriate, constrained only by the vague requirement to offer 'fair value' - a subjective standard with no enforcement mechanism."

Hannuman said the statutory regulator, the Council for Medical Schemes (CMS), has acknowledged that co-payments are a key driver of complaints and member financial risk. The Health Professions Council of South Africa (HPCSA) mandates that fees be 'fair and reasonable,' yet it possesses no effective enforcement mechanism to answer a fundamental question: what quantum of skill or ethics justifies a fee five times the benchmark?

“For patients, this is a profound betrayal. The doctor-patient relationship, built on trust, shatters when a life-threatening diagnosis is followed by financial catastrophe. Advocacy forums document emptied retirement savings, re-mortgaged homes, and severe psychological distress from 'bill shock.' The system monetises vulnerability at its most acute moment. Meanwhile, medical aid contribution increases consistently outpace inflation and salary growth, pushing quality healthcare increasingly out of reach for the middle class,” Hannuman said.

Hannuman acknowledged that healthcare professionals deserve fair compensation for their skill, risk, and sacrifice but questioned whether a 15-minute follow-up charged at 400% of the medical aid rate represents a fair exchange. A Durban doctor, who asked not to be named, said the out-of-pocket payments could be very high: “This is a very complex issue, and the cost could be 200% or more; that is why patients need to have gap cover.”

Brian Harris, general manager of Operations at Turnberry Management Risk Solutions, touched on the importance of gap cover: “In the current environment, medical aid alone increasingly leaves gaps. Specialist fees frequently exceed scheme rates, penalties for using non-Designated Service Provider (DSP) hospitals are becoming common, and co-payments can be significant.”

The South African Medical Association (SAMA) said it is not in a position to comment on the matter, as questions about above-tariff billing fall under the regulatory mandate of the Council for Medical Schemes (CMS).

“We recommend directing your queries to CMS, the HPCSA, or patient advocacy groups, who can provide authoritative and data-driven insights.”

While the Health Professions Council of SA asked to be sent written questions, it did not respond to several requests for comment.

THE MERCURY