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 expenses.
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 of waiting for the call centre to be of assistance. For more information, do not hesitate to contact us.
- Are you registered?
- How long have you been in this business?
- Do you have 24/7 support?
- Are you an independent broker?
- Can you give me quotes from different medical schemes?
- Do you charge additional fees?
- Will you assist with claims?
- Do you know the difference between a registered medical aid and medical insurance?
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 (PMB).
- 3 Month General Waiting period including Prescribed Minimum Benefit cover (PMB).
- 12 Month Condition-specific Waiting period.
- Late Joiner Penalty (LJP)
What are Prescribed Minimum Benefits (PMB)?
- Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members (including dependents) have access to certain minimum health services, regardless of the medical scheme they belong to and the benefit option they have selected.
- PMBs are included in the Medical Schemes Act and outlines the terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of the following:
- emergency medical conditions a set of 270 medical conditions 26 chronic conditions When a doctor needs to decide whether a condition is a PMB, the only thing to look at are the symptoms of the condition and not at any other factors, such as how the injury or condition was contracted. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).
- What to keep in mind when going for a planned PMB procedure in theatre in Hospital?
- It is very important to take note of the following:
- When going for a planned procedure and it is confirmed as a PMB, it is very important to know how your scheme covers planned PMB’s. This means that you need to confirm if you have to make use of specific designated service providers (Hospitals, Specialists etc.) or can you make use of any provider.
- If you have to make use of specific designated service providers and you prefer not to (out of choice), the scheme will only pay the normal medical scheme tariff / rate for the procedure according to their scheme rules.
- You will then have to pay the balance from your pocket or claim it from your Gap Cover. This however can become a problem, because not all Gap Cover products cover PMB’s.
- What does it mean if a benefit on my option is covered according / subject to PMB?
- This means that the scheme will cover the benefit / procedure equivalent to the treatment you will receive in a State facility.
- An example of this would be the following: You need to undergo a knee replacement and the knee prosthesis the specialist will be using costs R30 000. Your benefit for knee replacements on your medical scheme benefit option states that it is covered according to PMB protocols. A knee prosthesis used in a State facility costs R15 000 (for example), which means that the balance of R15 000 will be for your own pocket.
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:
- If you are joining a medical scheme for the first time and you have any pre-existing conditions (pregnancy, cancer, kidney problems, etc.) or you make use of any chronic medication, a 12 Month Conditions-specific waiting period will apply.
- If you have been a member of a medical scheme continuously for two years or less and you join a new scheme within 90 days of resigning from your current scheme, a 12 Month Condition-specific waiting period can be implemented, except in respect of any treatment or diagnostic procedures covered within the Prescribed Minimum Benefits (PMB).
- If you have been a member of a medical scheme continuously for two years or less and your current scheme did implemented a 12 Month Condition-specific waiting period, but at the time of resignation that 12 Month Condition-specific waiting period had not expired yet, the new scheme you are joining (within 90 days of resigning from your current scheme) can continue to implement the remaining month’s of the 12 Month Condition-specific waiting period.
- A medical scheme cannot implement a 3 Month or a 12 Month Condition-specific waiting period on a member who changes from one benefit option to another within the same medical scheme, except if that member is subject to a waiting period on their current benefit option. In such case, any remaining period may be applied and continued on the new scheme.
- A medical scheme cannot impose a 3 Month or a 12 Month Condition-specific waiting period on a child-dependant whom is born during the period of membership. Please do keep in mind that the child dependant must be registered on the medical scheme within 30 days from date of birth.
A medical scheme cannot impose a 3 Month or a 12 Month Condition-specific waiting period on a person who makes an application to join a medical scheme within 90 days from resigning from their current scheme, due to the following circumstances: Change of employment (meaning that it is compulsory to join your new employers medical scheme) Your employer changes or terminates the current scheme, effective from the new financial year. The employer however has to provide the medical scheme with reasonable notice of this change.
Exception: If the member currently has a waiting period on their current benefit option and it has not expired at the time of changing to the new medical scheme, the remaining period may be applied and continued on the new scheme.
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.