Why you need that insurance

If you belong to a medical scheme you may well wonder why you need to buy gap cover insurance as well.

Schemes reimburse doctors and other healthcare providers at different rates. If the rate at which your scheme pays does not match the rate your provider charges, you will be liable for the difference — and this, in the case of expensive hospital procedures or cancer treatments, can be large.

Marco Fonto, MD of gap cover provider Stratum Benefits, says recent claims included:

About R94 000 out of almost R157 000 that a neurosurgeon, orthopaedic surgeon and anaesthetist charged for a member’s spinal fusion operation;

About R8 300 of a R12 600 account from a gynaecologist and anaesthetist for a caesarean delivery; and

About R20 000 for a member who had two lung infections, a knee procedure and a colonoscopy in one year.

Jill Larkin, the head of GTC Healthcare Consulting, says as a medical scheme member you may think you are covered because your scheme pays specialists who treat you in hospital at 100% of the scheme rate. But this rate does not mean the scheme will pay 100% of what the doctor charges.

Since 2006 there have been no guideline tariffs for doctors and other healthcare providers. Schemes draw up their own reimbursement rates, often based on the 2006 guideline tariffs adjusted for inflation, but doctors, especially specialists whose services are scarce and in demand, set their own rates that can be as much as five or six times what your scheme pays.