The Government Employees Medical Scheme processes roughly R180 million in claims and 22 000 GP visits per day.
Picture: iStock
The Government Employee Medical Scheme (Gems) has paid out in a single year what one of South Africa’s largest private medical aids has distributed over 25 years.
The high volume of claims has forced Gems members to pay more for their plans from 1 April, following protracted negotiations with unions that settled on an increase.
Monthly payments for Gems members increased by 13.4% in 2025, with unions and management agreeing on a 9.5% increase for 2026.
Federation of Unions of South Africa (Fedusa) stated its displeasure with the increase, as public servants were only given a 4% salary increase for the coming financial year.
“The mismatch between wage adjustments and medical aid contribution increases is clear. Real income is being eroded. Workers are being forced to choose between healthcare and other basic necessities,” Fedusa stated.
22 000 GP visits per day
Gems was forced to implement the increase after what it stated was sustained financial pressure on its operations.
Gems’ four tiers range between roughly R1 700 per month to just under R5 000 per month.
Data recently released by the Department of Public Service and Administration show that Gems beneficiaries make significantly more regular use of their plans than some of the country’s top medical aids.
Gems has just over 2.3 million beneficiaries, with the department highlighting the regularity of claims.
The department’s written response to a parliamentary question stated that Gems paid out R67 billion in claims despite only collecting R65 billion in contributions.
The department registers roughly 100 new beneficiaries and 450 dependents per day.
Beneficiaries average 22 000 general practitioner consultations per day, 60 births, as well as just under 600 hospital visits per day.
Roughly R180 million per day in claims are paid out by Gems, as well as R27 million in specialist claims per day.
Getting paid to stay healthy
Previous annual reports released by Discovery show the company earned over R11 billion in profits across its South African and United Kingdom markets.
Discovery Health and Life earned operating profits of R3.9 billion and R4.7 billion, respectively.
At the end of December 2025, Discovery Health Medical Scheme had 2 725 122 beneficiaries.
The Discovery Health Medical Scheme also paid R75 billion in claims in 2025.
Resources dwindling
Gems was beginning to experience a shortfall in funds available for claims, having dipped into its reserves to the tune of R10 billion.
“The reserves of the scheme fell below the statutory requirement at the end of 2025.
“To ensure continued access to quality healthcare for public service employees, a delicate balance must be struck between financial sustainability and affordability,” the department confirmed.
The department also released the top 10 payouts received by claimants.
One claimant received an R11.4 million payment, with the next nine ranging between R7.4 million and R3.8 million.
The department did not explain the circumstances of the payouts, but confirmed they were the equivalent of the members’ total contributions.
The department has needed to institute “cost containment” measures to safeguard affordability.
Gems will aim to improve operational and network efficiencies and curb waste and fraud.
“These measures are aimed at minimising contribution increases while preserving benefit integrity and ensuring the scheme’s continued sustainability for its members.
“The scheme has further enhanced policies for supply chain management, officer vetting, and recruitment to prevent leadership instability,” the department confirmed.
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