How to in­sure

CityPress - - Business -

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.”

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