About Medical Co-payments in South Africa
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.
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.
- 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.
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.
Examples of Co-payments
- R1 000 to R1 500 for hospital admissions
- R1 500 to R3000 for MRI and CT scans
- R2 500 to R3 500 for gastroscopy, colonoscopy and arthroscopy examinations
- R8 500 to R10 000 for joint replacements
- R6 500 to R7 500 for abdominal, spinal and back surgery
Gap policies cover all of these co-payments with NO maximum claim limit.
- 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.
Gap 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.
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.
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.
Claims must be submitted within six months of the medical procedure or incident.
Additional lump sum and co-payment benefits specifically for first-time cancer diagnosis include:
- R25 000 once-off lump sum payment
- Co-payments of 20% for treatment charges above the cancer cover threshold, limited to R250 000 per individual annually
- Mastectomy – R20 000 for breast reconstruction
- Everyone included on the policy qualifies for payment of a R25 000 lump sum in the event of accidental death or injury
- R30 000 per policy annually for internal prosthesis if the medical scheme limit is exceeded
- “Hello Doctor” – a 24/7 text service for answers to medical questions
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 from R25 000 to R100 000
- 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.
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