JOHANNESBURG – South African households are bracing for another year of steep medical scheme premium increases, with major insurers announcing hikes of up to 9% for 2026 – nearly triple the current inflation rate of 3.3%.
The country’s leading open medical schemes have revealed significant increases across benefit options: Bonitas leads with 8.8%, followed by Medihelp at 8.46%, Discovery at 7.2%, and Bestmed at 6.8%. These increases come despite the Council for Medical Schemes recommending that premium hikes be limited to the Consumer Price Index plus reasonable utilisation.
Rising costs squeeze household budgets
The medical scheme increases add to mounting financial pressure on South African families already grappling with electricity tariff hikes, fuel price inflation, and rising food costs.
“For many households, medical scheme membership consumes a significant portion of monthly disposable income – yet it remains a non-negotiable given the state of the public healthcare system,” said Martin Rimmer, CEO of Sirago Underwriting Managers.
Even employees with employer subsidies are feeling the pinch as both workers and companies face tightening economic conditions, industry experts say.
The gap between cover and costs widens
Medical scheme members are increasingly finding themselves paying more for less coverage, facing escalating co-payments, penalties, and out-of-pocket expenses as schemes struggle to contain costs.
Analysis of gap insurance claims over the past five years reveals a sharp escalation in claim values, indicating both benefit erosion and a trend toward more affordable “core” hospital plans with limited coverage.
“A few years ago, the average mega gap claim was between R6,000 and R12,000,” Rimmer noted. “Today, we’re seeing daily mega claims exceeding R50,000.”
Gap cover protects members from shortfalls when specialists charge significantly above medical scheme tariffs – often 300% to 500% higher than agreed rates, leaving patients liable for differences that can reach tens of thousands of rands.
Strategic planning essential for 2026
Healthcare funding experts are urging South Africans to take a strategic approach to their medical cover as the deadline for benefit changes approaches. Medical scheme members have until the end of November 2025 to make changes effective from 1 January 2026.
Key considerations for medical scheme members
Industry professionals recommend several critical steps when reviewing healthcare cover:
Maintaining continuous coverage: Experts warn against delaying medical scheme membership, as late joiner penalties and waiting periods – including three months general and 12 months for pre-existing conditions – can prove costly.
Analysing spending patterns: Members should review their out-of-pocket expenses against medical scheme benefits to determine if they’re on the most suitable option.
Managing chronic conditions: Those with chronic illnesses should ensure conditions are registered with their scheme and covered under Prescribed Minimum Benefits, while verifying that prescribed medications are included in the scheme’s formulary.
Understanding self-funding capacity: Lower premiums typically mean reduced benefits, requiring members to realistically assess their ability to self-fund routine care and medication.
Securing cap cover: With specialists often charging far above medical aid rates, gap cover has become essential protection against potential shortfalls of R50,000 to R200,000 or more.
Evaluating hospital plans: “Core” or hospital-only plans cover in-hospital events exclusively, requiring members to self-fund all general practitioner visits, medication, dental, and optometry services.
Avoiding waiting periods: Staying within the same medical scheme when changing options helps avoid waiting periods, though “buy-ups” to more comprehensive plans are generally only permitted at the start of benefit years.
The bottom line
As South Africa’s healthcare landscape becomes increasingly complex and expensive, financial advisors stress the importance of professional guidance in navigating medical scheme options.
“The consequences of poor planning can be financially devastating,” Rimmer concluded. “Professional advice from accredited healthcare advisors is essential to understand benefits, exclusions, and options while ensuring adequate protection for both health and financial wellbeing.”
The 2026 premium increases underscore the ongoing challenge of balancing healthcare affordability with adequate coverage in South Africa’s two-tiered health system, where private medical schemes remain crucial for accessing quality healthcare despite their rising costs.
