MEDICAL AID AND GAP COVER

Introduction

Selecting the right medical aid plan and gap cover might be your worst nightmare. Our experienced healthcare consultants will assist you in choosing the most appropriate option for you and your family.

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Frequently Asked Questions

Why is choosing the right scheme/ plan option so important?

In a moment where you need medical attention, the last thing one wants to worry about is, the cost and affordability involved in order to restore you or your family to good health. One does not want to ‘over-cover’ or ‘under-cover’, therefore choosing the right scheme and plan option to fit your personal needs is key.

What are the key differences between a hospital plan and medical aid?

Both options cover your medical costs when in hospital, but a medical aid also provides day-to-day medical cover (outside of a hospital). If you are looking for a simple solution/plan option, in case of emergencies/accidents where hospital admission is required, a Hospital Plan will probably suffice.

What are the key differences between medical insurance and medical aid?

Medical aid and medical insurance are two different products. They fall under different legislation. The main difference is that medical aid provides in-hospital/day-to-day cover and pays for treatment according to the specific medical scheme tariff. Medical insurance traditionally pays out a set amount for each day spent in hospital or a set maximum amount per incident, regardless of the type of treatment that’s required.

What does Medical Aid Cover?

Medical aids cover hospitalisation, day-to-day cover, chronic cover and cover for management programmes, for example for cancer or diabetes. There are a variety of different plans to choose from. These plans vary to how much coverage and what type of coverage is included. One needs to ensure that you compare medical aid packages, premiums and coverage when choosing the best one suited for you. Medical aid schemes offer standard minimum health benefits in the form of PMB’s (Prescribed Minimum Benefits).

Do I really need Gap Cover?
There are certain expenses that medical aid will only cover in part causing a shortfall which the patient is then liable to pay. Gap Cover is designed to cover these shortfalls between what the Medical Aid is willing to cover and what the expense is charged by the private healthcare professional actually is. With most specialist accounts, there will be a shortfall and so Gap Cover is there to protect you.

A Visual Example of Common procedures and costs:

ProcedureActual CostMedical Aid CoverageWhat you would have to cover

Hysterectomy

R 12 978

R 4 751

R 8 227

Hip replacement

R 64 571

R16 326

R 46 361

Spinal discectomy

R 101 302

R 34 343

R 66 959

In the above illustration, Gap Cover would cover the amount of the shortfall, shown in the far-right column.

What does Gap Cover actually cover?

The core purpose of Gap Cover is to cover shortfalls on specialist accounts when hospitalised. Gap Cover has a variety of packages to choose from. Top-tier gap covers will cover in-hospital and specified out-of-hospital benefits/procedures up to 500% of the medical cost. In addition, they may also cover co-payments on hospital admissions, medical scans and cancer.

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Fairtree Private Client (Pty) Ltd is an Authorised Financial Services Provider. (FSP 12179)