Members of medical schemes should never be fooled into thinking they are safe from hospital costs. They are not, and this is why it is so vital to know where to get medical Gap Cover.
The Council for Medical Schemes and the Department of Health controls a pricing system. This system, known as the National Health Reference Price List, suggests payment tariffs and what medical schemes should pay out.
Because hospitals and doctors are not obliged to adhere to that pricing system, their final bills are often five times higher than what medical schemes are prepared to pay.
These shocking shortfalls then have to be paid by the medical aid member and often create financial nightmares for poor families.
All members of medical aid schemes are eligible to apply for Gap Cover
Gap Cover is normally available for less than R300 a month. And pays the difference between medical aid tariffs and costs of hospital treatments.
So where can you get medical Gap Cover?
There are many financial institutions that offer Gap Cover. Some of these include:
- ZestlifeZestlife Universal Gap Cover is offering the following enhanced benefits in 2019:
- Overall regulatory maximum for medical expense shortfall cover increased from R150 000 to R160 000.
- Cancer lump sum increased from R25 000 to R30 000.
- Casualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accident.
- Medical Aid and Gap Cover Premium Waiver maximum increased from R6 500 toR7 300.
- Medical Aid and Gap Cover Premium Waiver limited to accidental only, but the payment period increased from 3 to 12 months. This change was due to legal requirements.
- Accidental dentistry maximum increased from R15 750 to R19 250 and amount per tooth increased from R2 250 to R2 750.
- Non-Designated Service Provider co-payment increased from R8 600 to R9 300.
- Oncology co-payment maximum increased from 20% to 25%.
- Cover for robotic procedures up to R30 000.
- Cover for procedures in day clinics.
- New Oncology Benefit to cover 20% of treatment cost when oncology limit is exceeded.
- Varicose veins have been added as an out-of-hospital procedure that is covered.
Zestlife Premiums for 2021
- Covers the difference between medical aid payments and bills by up to 500%
- Also, in the event of death, stratum pays monthly premium for an agreed-on period
- Co-Payments – covers the cost to the medical aid member when having to pay their medical scheme up front for a portion of hospital procedures
- Oncology Benefits
- Outpatient Benefits
- Includes a number of cover options, including joint replacements
- Pays up to 500% more medical aid tariffs
- Co-Payments with chosen service providers
Also, there is a host of websites available for research about Gap Cover options. Clients should do careful research on medical aid options before they decide on any one company.
Premiums differ, depending on benefits selected. The more benefits selected, the higher the costs. Hence we urge clients to consult a broker before making a final choice.
Remember that only members of registered medical schemes can obtain Gap Cover
Members of any medical scheme qualify for Gap Cover and can change between medical aid companies as many times as they like.
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All info was correct at time of publishing