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We know the importance of medical aid gap cover. It boosts you in-hospital coverage so you can settle the portion of the claim your medical aid company doesn’t pay in full. But how does a medical aid gap cover company actually go about calculating and paying a claim that is submitted to them? I mean it’s nice to see the snazzy numbers in the marketing material but show me a proper claims handling example before I make my mind up. It’s a valid point so I managed to hunt down an actual claim paid by a medical aid gap cover company. Thank you to the guys at Turnberry Insurance Group for making the information available to me.

This particular claim was submitted under a Turnberry Insurance Group Pro-Care 100 top up policy. The policy boosted this client’s in-hospital coverage from 100% (covered by his medical aid) to 400% (the maximum coverage on offer with the guys at Turnberry)

Basically the medical aid top-up product was offering an additional 300% in-hospital coverage to Mr X. Luckily Mr X had the additional in-hospital coverage because otherwise he would have been seriously out of pocket.

So below are the numbers and you can click on the link at the end of the post to redirect to the actual claim I’ve uploaded to the site to verify what I’m saying.

There is a lot of information on the claim document, but these are the figures you need to look at:

Amount Claimed:            R15 489.99 (costs associated with the hospital stay)

Paid by Scheme:              R 5 278, 30 (amount the medical aid scheme settled)

Claims not Paid:               R10 211.69 (portion the member needed to pay)

So, the medical aid company stuck to their end of the bargain and paid R5 278,30 which was 100% of their tariff rate. That left Mr X with R10 211.69 in hospital expenses which needed to come out of his own pocket. Pretty heavy? You can’t believe how common this is nowadays. Specialists are charging exorbitant rates for their services.

So can Mr X claim the full amount (R10 211.69) back from Turnberry Insurance Group under his pro-care 100 policy?

Let’s have a look

R5 278, 30 (this is the 100% the medical aid covered)  x 300% (the additional coverage offered by Turnberry) = R15 834,90. The outstanding bill was R10 211.69 so it falls within the scope of the extra 300% coverage on the top up policy.

Claim paid!

R10 211.69 paid out directly to Mr X who squares off with the various service providers. It’s important to note that the contract was entered into between Turnberry Insurance Group and Mr X so the money is payable to Mr X and not payable to the medical aid scheme.

So here is the link to the actual claim document I’ve used in the example above. It will redirect you to our downloads page. Simply scroll down and find the document called Turnberry claim doc.

For R98 per month (and that covers everyone on your medical aid provided they aren’t already 65), the extra 300% insurance coverage is simply non negotiable. The question really is can you afford not to have  a medical aid top up policy?

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Until next time.

The InsuranceFundi Team


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