Warning: Medical aid probably won’t cover costs

December 18, 2021

If you have a medical aid and gap cover, you will need to beware of gaps in cover. These could be as a result of the anticipated new regulations that govern gap-cover products.

There are plenty of insurers who have already begun implementing the changes.

Not so long ago, there was a delay in payments to many policyholders due to disputes about liability for claims.

These related to conditions covered by PMBs or Prescribed Minimum Benefits. That is an area where insurers have started making changes to the gap-cover policies.

You can request a medical gap cover quote right NOW
by completing and sending the form on this page. Medical aid members only

Beware of Gaps – No Control over Specialists Charging their Own Rates

National Treasury has published a draft of the regulations under the Long Term Insurance and Short Term Insurance Acts. That is another attempt to separate what constitutes a medical scheme and what constitutes health insurance.

They also want to make sure that insurance doesn’t undermine the cross-subsidisation by medical aid members who are young and healthy over the older and sicker members.

Beware of Gaps in Medical Aid Cover

Gap-cover policies cover shortfalls between what your specialist who treats you in hospital charges and what your medical aid scheme pays to the specialist.

Recently that has been a massive uptake of gap-cover policies.

That is because the shortfall between what the medical aids pay and what the specialist doctors charge clients has widened significantly.

Because of Their Unique Skills – Specialists Will become More Expensive

Medical schemes have cut their benefits to contain their costs of contributions. Now the gap between what the specialists charge and what the schemes reimburse has spiralled. That’s because specialists are scarce, and there are no guideline tariffs for services.

The National Treasury has received submissions on the demarcation regulations including proposals to ban products that offer primary health care to the lower-income earners. They want to limit hospital cash plans to benefits matching R3 000 a day.

The earliest that these provisions in the regulations will occur is around January 2016, but that means possibly only January 2017. Nevertheless, the insurers have begun making changes to gap-cover products in anticipation of these changes.

by law, medical aids must provide PMBs or Prescribed Minimum Benefits. In fact, they have to be covered in full despite what doctors’ charge or other health care providers charge.

Beware of Gaps – Abide by the Rules or Else

Schemes can appoint particular doctors or health care providers known as DSPs or designated service providers. They will stipulate that you must use them so that your PMB claim is paid in full. If you don’t, except maybe in an emergency, it is likely that you will end up having to cough up yourself for a portion of the bill.

Sometimes claims are not coded properly by the healthcare provider, leaving members to face the shortfall themselves, because the PMBs were not treated according to the rules of the schemes.

In the past, gap-cover policies paid the shortfalls. Insurers have been called on to deal with a lot of gap-cover claims relating to PMBs being rejected. This is because the insurer was of the opinion that the policyholder’s medical scheme should have paid the claim.

Beware of Gaps – Know Where you Stand

If you have gap cover, you need to be careful. Things are becoming more complicated, more sinister, especially now with the new regulations coming into effect. It’s a new year – do your homework well, because what you got last year isn’t likely to be what you’ll get this year. Do your homework and understand what you are getting into and what your financial obligations will be.

You can apply for a medical gap cover quote right NOW
by completing and sending the form on this page. Medical aid members only

All info was correct at time of publishing