Ambledown celebrates 21 years of gap cover excellence

Johannesburg - As Ambledown approaches its 21st birthday in 2025, it reaffirms its commitment to offering competitive pricing and one of the most comprehensive gap cover benefits on the market, despite the challenges posed by soaring healthcare inflation.

Amidst unprecedented recent price increases by South Africa’s biggest medical schemes, Ambledown recently launched its 2025 Gap Cover product range with a focus on protecting consumers and continuing to fill the gap between healthcare provider charges and medical aid cover.

Tiago de Carvalho, CEO at Ambledown, said the shortfalls between medical scheme tariff cover and healthcare provider charges had reached levels where patients are now exposed to substantial financial risk.

Increase in Gap Cover utilisation 

“We are deeply concerned with the financial wellbeing of our members. Shortfalls on their medical bills have increased dramatically,” says de Carvalho. “Gap utilisation is up 15%. It highlights the dire need for gap cover. To make sense of the steep rise in gap utilisation over the last 12 months, our team analysed claim trends for 300,000 gap cover policies, representing 40% of the market.”

“What we found is that the rising complexity of surgical interventions and multiple procedures for the same condition have sharply increased the average cost per claim. Combined with the widening gap between scheme tariffs and provider charges, this has significantly escalated the portion of costs falling under gap cover.” 

“We expect this trend to continue, leading to a projected 15% to 17% increase in gap cover utilisation in 2025.”

Gap cover shouldering erosion of medical scheme benefits

Gap cover providers now bear a growing share of hospitalisation expenses traditionally covered by medical schemes. Based on an analysis of the top 20 mega gap claims, a recent report in The Citizen revealed a severe erosion of medical scheme benefits. Without gap cover, these claims alone would have forced members to pay a staggering R3 million out-of-pocket. In nearly half of the cases, gap cover paid more than the medical schemes, with shortfalls exceeding R100,000 per claim. On average, gap providers shouldered 40% of the medical cost of these claims.

“As medical schemes continue to reduce benefits amid rising healthcare costs, gap cover is becoming essential to protect members from crippling medical expenses,” says Michael Emery, Marketing Executive at Ambledown. “For us, as one of the leading gap cover providers in South Africa, we now really must focus on responsible risk pool management. We believe our members should always be certain that their gap cover will be there when they need it. That is why Ambledown prides itself on 21 years of data-driven decisions and ethical business practises. As the medical industry becomes ever more complex, we are using AI-driven data analytics to ensure Ambledown remains sustainable for the next 21 years and beyond.”

Significant medical scheme increases

Major schemes have announced significant increases, placing further strain on South African healthcare consumers. Increases come amidst pleas from the Council of Medical Schemes (CMS) to keep increases to 4.4% plus reasonable utilisation increases. While it is still subject to approval from the CMS, medical schemes have published increases far above the recommendation.

Medical Schemes Weighted Average Increases:

• BestMed: 12.75%
• MediHelp: 10.8%
• Bonitas: 10.2%
• Momentum: 9.4%
• Discovery: 9.3%

Speaking to Business Tech, Leo Dlamini, CEO and Principal Officer at Bestmed justifies the 12.75% average increase based on “increased demand for healthcare services by our members as well as the increasing cost of healthcare which is largely beyond our control.” This aligns with sentiments previously expressed by Craig Comrie, CEO of Profmed Medical Scheme, who highlights that rising healthcare claims costs are driven by new medical technologies and treatments, particularly in cancer care, which come at significant expenses.

Comrie stresses, however, that the primary factor is the increasing utilisation of healthcare services, with South Africa’s young population facing a high prevalence of diseases like cancer, cardiovascular conditions, and diabetes. Additionally, the aging population and growing rates of lifestyle-related conditions, such as obesity and hypertension, are further straining the healthcare system and pushing costs even higher.

With these medical scheme increases and the rising costs of medical services outpacing inflation, gap cover has become a vital tool to mitigate the financial impact.

Unchanged benefits: extensive protection

“As Ambledown heads into 2025, we are proud to announce that our Gap Cover benefits remain unchanged, apart from adjustments to the overall benefit limit to provide the maximum cover allowed by the regulator,” says de Carvalho. “Our product range continues to offer comprehensive protection our South Africans can trust.”

De Carvalho, particularly concerned that medical schemes are unable to keep up with new cancer treatments, says, “Ambledown is serious about modern cancer cover. We include numerous immunotherapy and hormone therapy treatments that offer our members the best chance for recovery.”

With no hidden limits or restrictions, Ambledown ensures that policyholders receive extensive cover, providing financial protection against rising healthcare costs.

Making life easier for brokers and members

At the 2025 Gap Cover product launch, Ambledown highlighted new digital innovations to help members and brokers. Upgrades to the AmChat AI-Assistant means brokers and members can get their queries answered, log in to their profiles, submit claims, track submission and much more, simply by starting a chat via the website or WhatsApp. 

Ambledown was also excited to introduce a new Broker Portal, launching at the end of Q1 2025. This fully integrated self-service platform will simplify the broker journey, streamlining administration processes and offering real-time support through a purpose-built AmChat AI-Assistant.

Additionally, Ambledown members can now access on-demand GP consultations through Intercare Clinic Online at discounted rates. Available from 1 January 2025, this value-added benefit provides instant access to medical professionals via any internet-connected device, empowering members to receive care from the safety of their homes.

These updates reflect Ambledown’s commitment to improving processes and services that make life easier for their members and brokers.

New tariffs for 2025

For the past 21 years, Ambledown has consistently maintained ethical business practices, ensuring the sustainability of the risk pool through responsible risk management and business strategies.

“While claims utilisation has risen significantly, we anticipate a more moderate trend in the coming year,” says de Carvalho. “We are incorporating the increases in medical scheme tariffs and allowing for modest widening of the gap between specialist fees and scheme rates. For 2025, our analysis shows medical providers will likely increase tariffs by 6% to 8.5%. With a weighted average premium increase of 9.1% for individuals and 9.5% for groups, we are confident that our pricing remains competitive, delivering essential protection without excessive financial strain.”

Emery concludes, “As South Africans face escalating medical scheme costs and eroding benefits, Ambledown Gap Cover remains a reliable solution to protect against rising healthcare expenses. With comprehensive coverage, competitive premiums, and innovative services, Ambledown is committed to ensuring that South Africans can access the best possible healthcare without the financial burden of shortfalls.”