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Do you need There are no laws regulating what medical specialists may charge you, and they are charging more and more, with cover by medical schemes falling further and further behind. For this reason you may consider taking out gap cover
GAP COVER?
THE growing values of gap cover claims show a marked increase in the shortfalls between what medical schemes pay versus what healthcare providers charge for in-hospital procedures. Recently, Sirago Underwriting Managers, a gap insurance provider, paid out almost R500k on just three claims for the gap portion alone. Without gap cover in place, a medical scheme member would be liable for this shortfall from his or her own pocket. Gap insurance covers the difference between the rate that healthcare specialists charge for in-hospital procedures versus what medical schemes pay. Unlike the pharmaceutical industry, there is no pricing regulation on healthcare provider tariffs, and with South Africa facing
a dire shortage of healthcare professionals, specialists are free to charge any rate, often 300% to 500% higher than the rate paid by medical schemes. If your medical scheme option only pays out at 100% of tariff, you will then be liable to pay the shortfall of the other 200% to 400% charged by your healthcare provider as an “out of pocket” expense, which can easily run into tens of thousands of Rands. “Sirago recently paid three large claims for cancer and musculoskeletal surgeries coming in at R153k, R142k and R162k per claim – until recently, claims of this magnitude were the exception, but are now becoming more common,” explains Martin Rimmer, chief executive of Sirago Underwriting Managers.
