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Gap cover insurance is a must have for consumers






JOHANNESBURG: The need for gap cover insurance in South Africa is greater than ever because without it consumers can be out of pocket to the tune of hundreds of thousands of rands following medical treatment.

Marco Fonto, the Managing Director of gap cover provider, Stratum Benefits, says in an actual case, a medical scheme member would have had to foot bills of more than R94 000 after his scheme paid out only R62 595 of the almost R157 000 charged by the neurosurgeon, orthopaedic surgeon and anaesthesiologist for his spinal fusion operation in November last year.

While hospital costs are paid for by medical schemes, it is the private fees charged by doctors and specialists that exceed the tariff at which medical schemes pay, by up to 300%, Fonto says.

The need for gap cover is due to medical schemes restructuring their benefits by paying more and more healthcare provider costs from members’ medical scheme savings accounts. In many instances, this means members are out of pocket a lot sooner because they use their savings to pay for shortfalls, he says.

There is also a trend for schemes to set up arrangements with designated hospitals which their members must use. Members that choose medical care from outside these designated networks must pay upfront pre-admission co-payments for which certain gap cover providers, such as Stratum Benefits, provide cover.

Furthermore, medical schemes impose co-payments for certain medical procedures which members must pay upfront from either their medical scheme savings accounts or from their own pockets.

These co-payments are increasing annually. For instance, Discovery Health’s co-payment on its Priority Series Plan has jumped by 20% for spinal surgery over the past three years while its co-payments for MRI and CT scans has increased by 13% over this period. Another large medical scheme, Bonitas has increased its co-payments for spinal surgery and for joint replacements by 30% each over the past three years.

The good news is that these co-payment amounts can be claimed back from gap cover insurance, Fonto says.

In a typical example of a claim paid out by Stratum Benefits recently for a caesarean birth, the total charged by the anaesthetist and the gynaecologist was R12 604 but the medical scheme covered only R4 242 leaving a shortfall of R8 362. In this case, the medical scheme paid for 39% of the anaesthetist’s bill and only 26% of the gynaecologist’s invoice.

In another example, a medical scheme member over the course of one year fell ill twice with lung infections and had to be hospitalised. He also had a knee procedure and a colonoscopy. His cumulative shortfall for the year – if he did not have gap cover – would have been almost R20 000.

The shortfall on his colonoscopy was R3 965, on his knee procedure was R4 992 and the two in-hospital treatments for his lung infections came to R7 785 and R2 427.

Fonto says families can enjoy gap cover for as little as R180 per month for Stratum Benefit’s basic gap cover policy. 

Source: Stratum Benefits
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