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Prior to 2004, medical schemes covered specialist services (in hopspital) at either the PRIVATE rate or at the MEDICAL AID rate. This changed in 2004, with most schemes reducing the levels of cover to 100% (aka the scheme rate).

As specialist rates have steadily increased over the last few years, there is now a large gap between what schemes will cover and what the specialist will actually charge. This results in members being ‘out-of-pocket’, even though they are members on a medical scheme. The Short Term Insurance Industry has therefore developed GAP COVER products, insuring members against this shortfall.

By way of example
In the event of you being hospitalised, your attending specialist/s will most likely charge between 300% and 400% of the medical aid tariff covered by your medical scheme.

Depending on the nature and length of time of your in-hospital procedure, this short payment could be a fairly significant amount, leaving you the end user significantly out of pocket.

Some actual claims:
Procedure Actual Cost Scheme Tariff Gap Claim %
Ceasarean Delivery R 10 537.19 R 2 689.80 R 7 883.39 393%
Appendicectomy R 3 595.23 R 1 198.41 R 2 396.82 300%
Coronary Bypass R 26 736.35 R 13 163.46 R 13 212.89 200%
Hysterectomy R 12 977.80 R 4 751.00 R 8 226.80 273%
Tonsillectomy R 12 297.70 R 4 119.91 R 8 177.79 298%
Wisdom Teeth R 6 260.00 R 1 958.50 R 4 301.50 320%

In addition, there is an increasing tendency within scheme options for self-funded co-payments. For example, Discovery & Momentum options now have co-payment amounts ranging from R 1000 to R 10,000 for a number of procedures including MRI/CT Scans, Dentistry, Endoscopic Procedures, Hospital Admission and more.

Most schemes have now also introduced a limit on Oncology benefits. Once that limit is reached, members have to fund 20% of the cost of their treatment plan.

The Solution
Top up your medical aid cover to meet these shortfalls with gap cover. We have contracts with five leading providers and can provide you with appropriate cover for your current medical aid plan. All providers governed by the Short-Term Insurance Act No 53 of 1998.