Gaps in Your Medical Aid Cover

If you are a member of a medical aid and have additional gap cover, you might think that you have full cover. There may be gaps in your medical aid cover due to once new regulations regarding gap covers take effect.

In anticipation of regulatory changes, many insurers have already started adjusting their products.

Up until recently, pay-outs to a lot of policyholders might have been delayed because of liability disputes.

For the most part, these disputes were regarding conditions that fell under Prescribed Minimum Benefits. It is in this area then that insurers have started to ring in the changes.


New Treasury Legislation

The National Treasury department has proposed a new set of regulations regarding long- and short-term insurance. This is in an effort to further differentiate a medical scheme and a health insurance.

Gaps in Your Medical Aid Cover

The other aim is to ensure that the insurance does not interfere with the cross-subsidisation of medical aids. Essentially, those who are young and healthy, and who do not claim often, subsidize those who need to claim more often.

Only South Africans who have medical scheme membership qualify for gap cover. Complete and send the form to get a quote


Gap Cover is More Popular than Ever

Medical professionals often charge more than the laid down Medical Aid Rate Tariffs. This has led to an increase in the amount of gap-cover that has been taken out.


Widening Gaps in Your Medical Aid Cover

With medical aids needing to become more competitive and keep member’s contributions lower, benefits are being reduced.

In addition, the cost of specialist care is increasing all the time. The skills are a rare commodity and so specialists are able to charge more.

Submissions to treasury. The National Treasury has been approached on more than one occasion to as regards demarcation regulations. Some petitioners proposed a ban on primary health care products for those earning a lower income.

Some petitioners proposed that a limit be placed on hospital cash plans so that they could not pay out more than R3 000 daily.

These changes are expected to start being implemented early in 2017.


Prescribed Minimum Benefits

Legally speaking, medical aids are obligated to provide Prescribed Minimum Benefits. According to law, they have to cover these fully, no matter what the health care professional charges.

They are, however, allowed to direct you to a specified network of providers. If you choose not to use these providers, they are not obligated to cover the full cost.

In other instances, the incorrect codes are used by the healthcare professionals and this leaves the members open to paying shortfalls.

Up until recently, these shortfalls would have been paid for by the gap cover. The gap cover insurers were having to deal with a lot of claims and claims started to be rejected. The reason stated for rejecting the claims was that the medical aid should have paid out.


What This Means for You

You need to know exactly when your gap cover will pay out and when it will not. You also need to know when your medical aid will pay out and when it will not. At all costs avoid gaps in your medical aid cover. That’s the expensive shortfall.

Take the time to fully understand the terms and conditions in both instances or you could be left short.

Complete and submit the form to get your gap cover quote – if you belong to a medical aid


All info was correct at time of publishing