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It’s the type of question you should be asking any insurer when looking to take out insurance cover: “How do you settle claims?” With medical aid gap cover insurance you’ve got several different parties involved, so who ends up getting the money at claim stage? That’s a good question.

Before I answer that question though, let’s have a look at the parties involved in this medical aid bill payment scenario. An example really is the best way to highlight how the process works.

You land up in hospital and six weeks later, while you are resting at home, the medical aid bill lands up in your post box. “Dear Mr Els, it’s your medical aid company here, you recently had procedure X done in hospital and this is how we have broken the claim payment down. The tariff rate for your procedure is R1000. Dr Venter, your specialist, charged R4000 for his work. We will settle the first R1000 of the bill because you are on a plan which covers you at 100% of our tariff rate. The balance of the bill (which is R3000) is for your account. Please settle directly with Dr Venter.”

The good news is that you have a medical aid gap cover policy in place. It’s going to pick up the portion of your in-hospital claim your medical aid doesn’t pay in full (up to 400%). So you submit your claim to your gap cover provider.

But hold on a second, you never asked how the medical gap cover company goes about settling claims?

Do they settle directly with you or do they settle the bill with your specialist?

The medical aid gap cover company settles directly with you.

Why not directly with your specialist?

Because the insurance contract in place (your gap cover policy) is between you and the insurer. Those are the only two parties involved in the contract, and as a result you are owed the claim payment.

So you get the money paid out to you and you settle directly with the specialist. Pretty straight forward right?

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Until next time.

The InsuranceFundi Team


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