Three reasons to get medical gap cover in 2012

Published on 23 January 2012

by In-house Writer

Feeling confident about your level of medical aid cover? Think again. Rapidly rising monthly medical aid contributions, benefit decreases and increasing gaps in medical cover are leaving medical scheme members exposed to significant financial risk in 2012.

New medicines, treatment technologies and research are driving up costs from the medical schemes' perspective, with claims too becoming incrementally more expensive.

Such cost increase typically lead to increasing contributions, or reduced benefits, or both. In order to remain sufficiently liquid, many medical aid schemes are opting to increase payout gaps – the difference between what is covered, and what you need to pay out of your pocket before additional high-cost cover thresholds are reached and you are once again covered for major surgical procedures and the treatment of certain dread diseases, among other costs.

For most medical scheme members, and for hospital plan members, in particular, shortfall payments are already a reality. Understanding your particular medical aid's shortfall structures or cover gaps is key to avoiding substantial out-of-pocket medical expenses:

1) Your bills could exceed your plan's benefit limits

Once you hit your medical aid plan's benefit limit for a particular type of claim, it becomes an out-of-pocket expense. Your pocket, that is.

Most medical schemes cap you in two ways: they enforce an annual overall limit on claims, as well as secondary limits on specific types of claims. After a serious accident, the cost of surgery, lengthy hospitalization as well as post-operative treatments such as physiotherapy can all contribute to you hitting your annual overall claims cap.

It is also quite likely that you can also hit certain benefit specific claims benefits, especially if you have a serious chronic condition requiring expensive medication and/or treatments. Benefits such as day-to-day GPs' bills, dental benefits, radiology, pathology and the annual allowance for prescription spectacles are typical examples – all of which can very quickly run into thousands of rands of uncovered costs.

It is therefore of vital importance that you opt for a medical aid plan that is life stage appropriate and well suited to your unique needs. Also be sure to double-check your plan's payment caps, as well as the rules regulating benefit gaps on treatments you may need.

2) Doctors' rates can exceed recommended Medical Scheme Tariffs (MSTs)

Supply and demand pressures are evident when it comes to specialist medical practitioners' fees. Surgeons, radiologists and anesthetists can legitimately charge whatever they want, with their fees frequently being as high as 300% of recommended Medical Scheme Tarrifs, or MSTs. The difference between their fees and your scheme's benefit is for your account, and is better known as the "tariff shortfall".

For example, if the bill is R30,000, at 300% of MSTs, and your scheme only covers you for 100%, you'll need to pay R20,000 out of your own pocket. Especially if you aren't able to work for a while as a result of an accident or serious illness, this type of unexpected expenses can wreak havoc with your budget.

A medical gap cover policy from Instant Life can provide you cover against this eventuality. Another way is to use only doctors recommended by your medical scheme, and who fall within your scheme's rate structure.

3) You may need to register certain conditions to claim

Certain medical procedures or medical expense payouts may be subject to pre-authorisation. For conditions and diseases such as hypertension, HIV, high blood pressure, asthma, diabetes, heart disease, your medical scheme may require you to register on a disease management programme, with failure to do so typically leading to reduced claims payouts or outright claims refusal.

Be sure to contact your medical scheme to establish what you need to do before it comes to a time when you need to submit a disease related claim. Also routinely re-check your scheme's rules in this regard to ensure you stay covered.

Protect yourself with a medical gap cover policy

If you're worried that your existing medical aid cover may be inadequate, why not investigate a medical gap cover policy from Instant Life? With up to R2 million in cover per year for just R128 per month, it can offer you the peace of mind that an unexpected illness or serious accident won't ruin your finances. For a free, fast quote, simply click here./p>

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