About Medical Co-payments in South Africa

November 30, 2024

What are medical co-payments?

  • Avoid co-payments for hospital admissions with gap cover
  • Avoid medical co-payment for certain medical procedures with gap cover
  • There are NO maximum claim limits
  • Immediate cover for accidental injuries
  • Cover for first-time cancer diagnosis
  • Immediate cover for first-time cardiac-related conditions

 

Overview of medical co-payments

Gap cover is not a medical aid or medical scheme.

It is a medical insurance policy that covers all dependants on the main members’ policy with the exception of multiple spouses.

Medical schemes set the amount they will pay for each and every medical treatment they will cover.

This is known as the Medical Scheme Tariff (MST).

The medical scheme will set the MST amount at 100%, 150% or even 200%, depending on the option selected.

However, surgeons, anaesthetists and other medical professionals are free to charge whatever they like.

With the result that charges imposed on a medical scheme member are substantially higher than the MST.

A Universal Gap Policy by Liberty Medical Gap cover takes care of this unpaid shortfall.

Let’s take a look at an example to illustrate this point about medical co-payments

Michelle is hospitalised for a routine appendix operation.

Everything goes according to plan and there are no complications.

She is in and out of hospital within two days.

One week later Michelle receives the hospital account.

She is not expecting any surprises because she is on a medical option that pays 100%.

But this is Michelle’s problem.

The account

  • Surgeon R10 200.83
  • Anaesthetist R7 544.00
  • Total R17 744.83
  • Medical Scheme Tariff @ 100%
  • R7 247.75
  • Unpaid shortfall R10 496.63

If Michelle had a Universal Gap Cover medical co-payments policy from Liberty the shortfall of R10 000+ would have been covered.

Universal Gap Cover pays up to five times the MST with NO claim limit.

Co-payments

Gap policies also cover co-payments.

These are payments charged by medical schemes that require upfront payments from members to access certain medical facilities and treatments.

Medical schemes use these medical co-payments in a similar way that car insurance uses excess payment charges to discourage unnecessary and over frequent claims by their members.

Qualification criteria

  • To qualify for gap cover, the procedures resulting in the shortfalls must be approved by the medical scheme.
  • Remember, gap cover only pays for shortfalls on doctor and specialist charges.
  • It does NOT cover medicines or ward fees.

 

Exceptions

Medical Co-paymentsGap policies typically only cover procedures that take place in hospitals but there are exceptions.

About 50 procedures that can be conducted outside a hospital are covered by gap policies and these are all listed in the policy document.

Limitation and conditions

Routine daily medical costs are not covered.

Other general exclusions include nuclear weapons, warfare, injuries sustained while participating in a criminal act, speed-related events such as car racing, alcohol and drug abuse.

Waiting periods

No claims will be paid for:

  • Three months from the inception of the policy
  • 10 months for birth-related procedures
  • 6 months for joint replacements, arthroscopic procedures, spinal surgery, nasal and sinus surgery, dentistry, hernia repairs, cataract surgery, hysterectomy and cardiac procedures

However, these nine conditions qualify for 50% of the normal benefits during the second six months of the policy.

Full cover benefits for these nine conditions commence when the policy is one year old.

Immediate cover

The Universal Gap policy covers accidental injuries from day one of the policy.

This benefit also extends to hysterectomies due to first-time cancer diagnosis and cardiac procedures diagnosed after the inception of the policy.

Claiming

Claims must be submitted within six months of the medical procedure or incident.

Optional extended cover

Over and above the standard gap policy cover, Liberty also offers optional extended cover for cancer and dental procedures.

  • Cancer – cover is extended
  • Dentistry – policyholders are covered for emergency, accidental and specialised treatments

To obtain optional extended cover for medical co-payments applicants must be under the age of 65 years and are subject to a six month waiting period.

 

Get a gap cover quote from a leading supplier by completing and sending the form on this page. Take care of medical co-payments that way.

 

All info was correct at time of publishing