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So what’s in a name I hear you ask? Quite a bit actually. Medical Gap Cover and Medical Aid Top Up cover might look like the same product on the surface but when you drill deeper you will find a significant difference between them.

Medical aid top up insurance does exactly what the name suggests. It tops up your in-hospital coverage (the difference between what the medical aid scheme actually pays and the Specialist charges).

Let’s look at a quick example:

You belong to a medical aid plan that covers your in-hospital costs at 200% of the scheme rates. You don’t think that is enough in-hospital coverage (and you are right, it isn’t), so you quickly take out a medical aid top up policy. The policy provides you with another 200% in-hospital coverage, so in total you’ve got a total of 400% in-hospital coverage. You’ve topped up.

Excellent, now you are covered in full.

Let’s take the example a little further to claim stage.

You land up in hospital and the Specialist you use isn’t contracted in at medical aid  rates (none of them are nowadays). He charges R40 000 for the procedure and let’s assume, that the medical aid scheme tariff rate for the operation is R10 000.

You see the problem emerging? A shortfall which is going to become your problem.

Your plan covers you at 200% of scheme rates so medical aid will pick up the first R20 000 of the R40 000 bill. Not a problem. You’ve got the medical aid top up product, so you shoot the bill off to them. They cover you at another 200%, so they pay you out the remaining R20 000 and you settle with the Specialist.

All squared off. Nobody owes anyone anything. What a relief…

Now, let’s look at how a real medical aid gap cover product works and we can use exactly the same example to illustrate the major difference.

Zestlife’s Medical Aid Gap Cover policy always pays the difference between 100% of tariff and what the specialist charges no matter what medical aid plan you belong to.

If your medical aid plan picks up more than 100% of tariff you will have the extra cash available to you. Simply put it in your pocket.
Let’s look at the same example. Your Specialist bill was R40 000 right? Your medical aid plan picks up you in-hospital costs at 200% of tariff. The tariff rate for a procedure like the one you had is R10 000, so your medical aid’s got the first R20 000 of the bill.
You still owe the specialist R20 000. In the example above, the medical aid top up company paid the rest (the balance your scheme didn’t pay)

Now, stay with me..

Zestlife pay bills at 100% of tariff regardless of the medical aid plan you are on. So you submit the same bill to them, but instead of picking it up at 200%, they pick it up at 300% and you get R30 000 back rather than R20 000.
But hold on a second, I only require R20 000 to settle with my Specialist. Do I get to keep the additional R10 000. The answer is yes. With Zestlife’s Medical Gap Cover Product you keep the balance because they always pay bills at 100% of tariff regardless of the plan type you are on.

It makes sense to cover the gap, rather than simply topping up your in-hospital coverage.

Kind regards,

The InsuranceFundi Team

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