How to insure
Medical schemes argue that as long as you only use their network of providers and hospitals, there will be no need for gap cover because the specialists in this network have agreed to the medical scheme tariff.
However, independent financial adviser Duncan Barker says that the network is not necessarily a protection against shortfalls, especially if you are on one of the smaller medical schemes, because they do not have large networks of providers and finding one near you can be challenging. In my case, the surgeon was not part of my medical scheme’s network, hence the shortfall, but he was part of another, larger scheme.
Barker says that the size of the network becomes more of an issue in the case of an emergency because you may not be able to choose your provider.
“Even if you are within a network hospital in an emergency, the specialist who ends up treating you may not be a network specialist, in which case you may have to pay in the difference.”
Even if you are on a network arrangement and are using a network specialist, copayments may apply, depending on the procedure, as in my situation. This copayment can be covered by gap medical insurance.
As gap cover is becoming more popular, Barker says there have been cases of specialists asking patients whether or not they have gap cover.
“If you do, they’ll charge their maximum rate because they know that your gap cover will probably pay. In so doing, this product is actually creating a market for itself in the industry. Specialists are beginning to see that they don’t necessarily have to belong to a network, because more people have gap cover and they can then charge their higher rates. It is a self-fulfilling product, in essence,” says Barker.
Understand the cover
Like any insurance product, the more comprehensive it is, the more you pay for it. Gap cover ranges from as little as R120 a month up to R300 a month, so you need to know what is included. Some only cover shortfalls between the doctor and the medical scheme, while others include the copayment on elective procedures. More comprehensive cover will include a visit to the emergency room (normally, this is not considered to be in-hospital care, because it is run as a private practice), as well as additional benefits for oncology, including a lump sum to pay for prosthetics.
Also be aware that this is an insurance product and not a medical scheme. Gap-cover products apply insurance principles to manage risk, so they impose waiting periods and exclusions for a period of time. They can also exclude specific conditions.
Barker says an example of a waiting period would be for a pregnancy, which would be excluded for 10 to 12 months from the inception of a policy.
“So if you are pregnant already, it won’t help to implement this. But your children, when they are born, will be covered in full.”