Select Page

SA's No 1 Insurance Blog

Not another darn unpaid medical aid bill. Why do I pay my premiums? I thought I was covered in full!

Sound familiar? Trust me I know the feeling. I recently had a few “Not paid by your medical aid provider” bills landing up in my own mail box.

I’m not a big proponent of pushing products, but when I find something I feel is absolutely necessary to include in your own insurance portfolio I’m going to mention it.  If I didn’t I would be doing our clientèle a major disservice.

So what insurance product is so important that it requires a full blog post mention and an sms?

It’s medical aid top up cover and I strongly believe nowadays you can’t afford not to own a policy like this.

Why top up your medical aid?

It’s simple really. The cost of private health care is sky rocketing and as a result medical aid schemes are covering less and less of the expenses associated with in hospital procedures.

Have you noticed that your premiums are going up while your coverage is staying level – or in some cases –coming down?

That means that the likelihood of you receiving a bill in the post box after visiting a hospital, even if you are on a good medical aid plan, is increasing with every passing day.
Enter the savior of the day (medical aid top up insurers), here to rescue us from our plight. They offer a medical aid top up cover policy designed specifically to top up your in-hospital medical aid coverage and in my opinion it couldn’t have come sooner.

I’m going to be honest. I didn’t know that an insurance product like medical aid top up cover even existed until last year sometime.

I had heard the term “medical aid top up cover” being thrown around a few times at the occasional broker get together but I wasn’t sure exactly what it was and more important what it covered. So I did a little investigation work (true to our style) and ultimately we contracted ourselves with a bunch of guys at the Turnberry Insurance Group. They have a range of different “top up” products but by far the most important one in my opinion is the Pro-Care policy. I will get into the product tech spec a little later in the post..

What are Medical Scheme Rates (MSR) all about?

One of the biggest differences between medical aids and the plans on offer nowadays is the percentage of your medical bill they are willing to pay. In other words, the discrepancy between your actual bill and what they’re willing to pay differs from plan to plan.

Let’s look at an example of a Hip Replacement Surgery:

Service ProviderTotal CostMedical Aid Tariff-100% coverPro-Care 100Medical Aid Tariff-200% coverPro-Care 200
Hospital Co-PaymentR3,500

Note: R248 of the anaesthetist’s bill exceeds 400% cover and is payable by the client. You will also see the benefit of the “top up cover policy – Pro-care 100 and 200” which I will get into a little later. It pays the portion of the bill your medical aid provider doesn’t cover.

Why isn’t your medical aid scheme picking up all the bills? It’s because of supply and demand. You want the best neurosurgeon out there? Then be willing to pay for his services (Did I mention that new BMW’s don’t come cheap.) Medical aids therefore agree to pay members claims at pre-determined rates. The more you spend on your medical aid plan, the higher the rate of coverage you will enjoy. Just like a motor car. The more you spend on a vehicle, the better the specs.

Generally the top of the range medical aid plans in this country will cover expenses at 300% of the agreed scheme rate. Middle of the range plans will cover you at 200% and entry level plans at 100%. (I’m yet to find a medical aid plan that covers you at 400% – imagine the cost!). Remember these numbers (100%, 200%, and 300%) because we are going to use them in a few calculations later on.

Example of how scheme rates are applied.

Medical scheme company (A) does a study on the average cost of Medical Procedure (X)

Based on this information they decide to set their scheme rate at R1,000. The specialist however charges you R3,000 for procedure (X) Why? Because he can, that’s why!

You’d think because you are on a medical aid you are covered, right? That’s why you pay the big bucks each and every month. You are only partially correct and this is why those sneaky unpaid medical bills pile up in your mailbox.  If your medical aid plan only covers you at scheme rates 100% (R1,000) you are going to be 200% ( R2,000) under-insured. This means that R2,000 of the R3,000 bill is for your own pocket.

Ouch ..Why? Because the plan you chose only covers 100% of the scheme rate. Your specialist sends them a bill for three times that amount. The scheme pays what they said they would..and you get billed for the balance. It’s ugly but that is how it works.

If you plan covers you at 200% of scheme rates, you would still be 100% under-insured and you are in for R1,000 (expect the bill in your mailbox!) and if you plan covers you at 300% of scheme rates then you can breathe a huge sigh of relief – your bill is covered!

So this is the big problem nowadays. The cost of medical treatment is going up and quite frankly the coverage offered by medical schemes isn’t staying in touch anymore (unless you can afford a super-dooper medical aid plan which few of us can). I am not talking about the day-to-day medical expenses here like the odd GP visit, some medication over the counter or a quick filling at the dentist.

If your plan has a medical savings account (MSA) you can handle these types of expenses, even pay them out of your own pocket. I’m talking about the heavy hitting bills that are associated with in-hospital procedures. It’s these expenses that are hard to bounce back from financially. Where do you find the extra money lying around?

And that’s where the Pro-Care Medical Aid Top Up Policy by Turnberry Insurance Group comes in..

I like this product so much that I signed up myself and actually just received my policy document in the post.

This is what I like about it. Firstly the idea behind the pro-care product is to top-up in hospital medical aid coverage to a maximum of 400%.

Let me explain…
The pro-care policy is attached to your medical aid plan (any medical aid scheme by the way). If your medical aid plan offers you coverage at 100% of scheme rates as discussed earlier, then the pro-care plan will cover you for another 300% taking your total coverage up to a max of 400%.

Example: You have a medical aid plan with company (x) which covers you at 100% of scheme rates. You take out a pro-care 100 top up policy which covers you for another 300% and your total coverage is now 400%. Any claim that isn’t settled by your medical aid will be paid by the top up insurer provided:

  • it falls within the 400% range
  • is a legitimate claim covered by the policy, and
  • authorized by your scheme

Remember the total coverage is 400%, so if your medical aid plan covers you at 200%, then you take out another 200% top up. If your plan covers you at 300%, then you take out another 100% coverage. Got it?

Percentage of claims which exceed the tariff amount

I know what your next question is going to be.

What % of claims are not being paid by  medical aid providers?

I was interested in finding out myself and the good guys at Turnberry have been kind enough to provide me with the latest claims graph. It’s scary stuff!

If you are on a medical aid plan that covers you between 100% – 200% of  tariff rates (which is the standard option), there is a 50% likelihood that the your medical aid bill isn’t going to be paid in full!

Wow that is a shocker. Even the guys on the seriously comprehensive medical aid plans who thought they might be safe because they pay big premiums obviously need to re-look their coverage options (30% of their bill won’t get paid!).

So what kind of premiums are we talking about here?

Cheap as chips and you will agree. Below is a rate table for the different top up plans covered under the pro-care policy.

The premium payable not only covers you, but also your spouse and children. In my case it’s the pro-care 200 plan at R72 a month.

It’s a small price to pay to ensure that my wife and I are properly covered.
Oh and there is an extra benefit included in the policy… It’s R1000 000 international travel cover offered through Netcare 911 anywhere in the world, anytime. Just give them notification 48 hours before your departure.

Pro-Care 100R98pm
Pro-Care 150R80pm
Pro-Care 200R72pm
Pro-Care 300R55pm

What else should I know before I sign up?

If you are joining a new medical aid plan you can add the pro-care benefit immediately. If you are an existing medical aid member like many of us, then there is a general 3 month waiting period before you can claim.

There is also a 9 month waiting period for maternity benefits.

At application stage there will be a few underwriting questions, so the insurer reserves the right to perhaps exclude pre-existing health conditions. The maximum benefit payable in a year is R500 000 per insured on the policy and R1 500 000 per family.

Please also note that you can’t put in a claim for a procedure that wasn’t authorized by your medical aid. So if you are wanting that nose job done and your medical aid says “Oops, it’s cosmetic surgery. We don’t cover that!”..then don’t expect Turnberry to pay. Only claims submitted to your medical aid and which have been authorized, count.

So how would I go about submitting a claim?

Easy enough. Your unpaid medical bill lands up in your mailbox. You submit the bill to Turnberry. Provided it falls within the 400% limit they will pay you directly. You then in turn settle the bill. Claims need to be submitted within 6 months from the date of treatment.

If you would like more information on the pro-care product contactus now by redirecting to our quick info capture form. Pop in your details and hit submit. We will be in touch soonest.


PS: If you haven’t already signed up to the blog, please do so by going to the top right hand side of this page – subscribe via email. Simply input your name and email address, hit the “subscribe” button, and wait for the verification email which will be sent to your in box. Please click the blue link in the email and help yourself to a brand new copy of our life insurance e-book.

Lastly, if you liked this article, please post your comments below..or tell us about your experiences with unpaid medical bills.


Copy link