It's common to hear people talking about medical aid, medical insurance and gap cover, but many consumers don't know the difference and, therefore, do not know which option best suits their needs.
The consequence of an uninformed choice affects citizens every day.
At Riskfin, we will provide you with the solution that best suits your needs.
Riskfin has contracts with a number of authorised services providers dealing with medical aids, medical insurance and gap cover.
Everyone needs some form of medical aid cover. Few of us could afford the costs of prolonged hospitalization or medical care for serious injuries, surgery, or chronic illnesses –hospitalization could cost R8 500 per night to stay in a private hospital, and that’s just for the bed, without any consultation fees, medicine or medical supplies.
Medical schemes help us finance life’s curved balls when we can’t do it alone.
This type of insurance is more commonly known as a Hospital Cash Plan. A hospital cash plan is a benefit plan that allows for cash payments to the person who is hospitalised for every day that the person is hospitalised. This type of plan is aimed at giving the individual extra cash on hand to cover additional medical.
In South Africa, and many other countries around the world, private health care is expensive. Many people mistakenly believe that their medical aid will cover all the costs associated with an illness or accident, but medical aids don’t always foot the bill for all the medical services, medication or therapy that you may need.
In some instances, private medical practitioners charge more than your medical aid is willing to pay for their services. In such instances, it may seem like your only option is to ask the medical practitioner to charge less or request your medical aid to pay more. In both scenarios, you are likely to be unsuccessful. How could you cover the gap between what you need to spend on medical care and what your medical aid is prepared to pay for the medical care?
Medical aid gap cover is designed to cover the gap created when your doctor or specialist charges more for in-hospital services and treatment than the amount refunded by your medical aid.
Just because you have been diligently paying your monthly medical aid bill, doesn’t mean you are covered in the event of an unexpected accident or disease.
Riskfin is a registered independent brokerage and can assist you to make the right choice when you choose a medical aid. We deal with multiple registered medical schemes and will provide you with free quotations. The benefit of using a broker is, we assist you to choose the best option for your needs. Our friendly team can assist with queries like unpaid claims and so forth. It saves the member the frustration waiting for the call centre for assistance. For more information, do not hesitate to contact us.
When joining any open medical scheme in South Africa, the medical scheme has the right (in reference to the Medical Schemes Act of South Africa No. 131 of 1998) to implement underwriting on any member joining that scheme.
This underwriting entails the following:
3 Month General Waiting period excluding Prescribed Minimum Benefit cover:
This is a period in which the member cannot claim for any benefits from the medical scheme and is applicable from the members start date. Once this period has passed, the member will be covered in full (except for any pre-existing condition which received a 12 Month Condition-specific Waiting period) and according to the scheme rules and benefit option. 3 Month General Waiting period including Prescribed Minimum Benefit cover:
This is a period in which the member cannot claim for any benefits from the medical scheme and is applicable from the members start date. The member will however be covered for LIFE THREATENING emergencies and conditions as covered within the Prescribed Minimum Benefits (PMB). This includes cover for the 26 PMB Chronic conditions. Once this period has passed, the member will be covered in full (except for any pre-existing condition which received a 12 Month Condition-specific Waiting period) and according to the scheme’s rules and benefit option. 12 Month Condition-specific Waiting period:
This is a period during which a beneficiary is not entitled to claim benefits in respect of a specific condition for which medical advice, diagnosis, care or treatment was recommended or received within a 12 month period prior to the member’s start date. This means that any existing medical condition (cholesterol, diabetes, back problems etc.) will be excluded for 12 month’s from start date of the membership. No medical scheme claim linked directly to the condition will be paid for within the 12 month’s. When will or won’t underwriting be applicable?
3 Month Waiting Periods:
If you are currently a member of a medical scheme and have been for a continuous period of less than two years and you join a new scheme within 90 days of resigning from your current scheme, a three-month waiting period may not be implemented. When you have been retrenched or you are going on retirement and you were on your company’s closed medical scheme (like Wooltru, Polmed, Sasolmed, Bankmed, etc.) with no option to continue on that medical scheme and you then join an open scheme (Fedhealth, Medihelp, Discovery, etc.), that scheme cannot implement a three-month waiting period. 3 Month General Waiting period excluding PMB cover:
This waiting period can be implemented on all members joining a medical scheme for the first time ever and on members that are joining after a break of more than 90 days from resigning from their previous medical scheme. This means that for the first 3 month’s you will not have any cover and should anything happen, you will have to make use of state facilities for medical treatment. 3 Month General Waiting period including PMB cover:
This waiting period can be implemented on all members joining a medical scheme who have been a member of a medical scheme continuously for more than two years and who joins a new scheme within 90 days of resigning from their previous scheme. 12 Month Condition-specific Waiting period:
When you have been retrenched or you are going on retirement and you were on your company’s closed medical scheme (like Wooltru, Polmed, Sasolmed, Bankmed, etc.) with no option to continue on that medical scheme and you then join an open scheme (Fedhealth, Medihelp, Discovery, etc.), that scheme cannot implement a 12 Month Condition-specific waiting period. A 12 Month Condition-specific waiting period can be implemented on the following basis:
This is a penalty (financial) that can be implemented on all members, over the age of 35. The penalty is only calculated on the Risk portion of the total monthly premium and is paid every month for as long as you are a member. To avoid such penalty, you have to provide the scheme with proof of previous medical scheme membership through a sworn affidavit or membership certificates.
How the penalty is calculated:
They take your current age and deduct the total amount of years you have been a member on a medical scheme. They only calculate years and not month’s. The amount must be 35 or less to avoid a penalty.
Example: If you are 50 years old and have belonged to a medical scheme before (Liberty 10 years, Discovery three years), deduct 13 from 50 = 37. Your LJP will be 5% – see table below.
Adjusted age: : LJP
36 – 39 5%
40 – 49 25%
50 – 59 50%
A medical scheme cannot implement a Late Joiner Penalty on any member over the age of 35 who has been a continuous member of a medical scheme prior to the 1st April 2001 without a break in coverage of more than 90 days.
Example: : If you are 65 years old, currently on a medical scheme and you have been continuously, (this can be more than one scheme) from the 1st March 2001 (or prior to this date), without a break in coverage of more than 90 days between the scheme memberships, the new scheme you are joining cannot implement a Late Joiner Penalty.