Don't let Medical Aid shortfalls cripple you financially

Why do I need the Gap Cover benefit when I have a Medical Aid? Surely my Medical Aid will cover all my in-hospital expenses?

Not so! The rate at which Medical Aid Companies are prepared to pay for in-hospital procedures and the rate at which the service providers charge are two worlds apart.

Medical Aids utilise the Reference Price List (RPL) tariff issued by the Council for Medical schemes when setting their Medical Aid rate and determining at what rate in-hospital benefits will be paid, whilst Medical service providers usually charge for their time and expertise at a rate far in excess of the Medical Aid rate.

What implications does this have for you the end user?

More often than not, there will be a short payment on your in-hospital procedures account, due to the service providers charging in excess of what your Medical Aid is prepared to cover. This can in some cases be as much as three or four times the Reference Price List tariff.

Depending on the nature and length of time of your in-hospital procedure, this short payment could be a fairly significant amount, leaving you the end user significantly out of pocket.

An example of such a claim is listed below:

CompliMed has also noted an increasing tendency within scheme options for more and more self-funded co-payments. For example, Discovery & Momentum options now have co-payment amounts ranging from R 1000 to R 7300 for a number of procedures including MRI/CT Scans, Dentistry, Endoscopic Procedures, Hospital Admission and more.

The SOLUTION

Either upgrade the option within the Medical scheme, at a significant increase in premium (15 – 20% in most cases).

OR

Self - insure through CompliMed, who has recognised this potential shortfall and created its range of GAP products to cover these payment shortfalls and co-payments.

All these products are defined as an "accident and health policy" under the Short-Term Insurance Act No 53 of 1998.