SA's No 1 Insurance Blog

Belonging to a medical scheme is expensive, make no bones about it. Don’t expect much for anything less than a R1, 000 a month.

So imagine a hospital stay for something minor and then having bills start piling in. First it’s the surgeon’s bill followed closely by the anaesthetist’s and before you wipe your eyes out, you owe R5, 000, R10, 000, or how about R100, 000?

Take natural childbirth for instance.

Surely your medical scheme should pay this in full?

We’re no experts on childbirth, but surely there’s no surgery taking place here, is there? So how on earth did Zestlife end up paying R18, 464 towards an expense which should have been paid in full by the medical scheme?

So what exactly is gap cover?

Gap cover pays the gap between what your medical aid is prepared to pay, and what the specialists performing the operation are charging. The difference between these two can be huge.

As I write I’m looking at the Zestlife 2018 brochure and I see a few biggies.

  • Take hip replacement surgery for instance – in 2017 they paid R66, 178 – and that’s just one claim!
  • Or how about cardiac bypass surgery? R107, 069 paid for one claim!

So don’t get too excited at finding a cheap medical aid when just one visit to hospital could leave you with unpaid bills of R100, 000.

Another problem is co-payments. Often, the cheaper your plan becomes, the more and more co-payments start popping up. Imagine going in for a joint replacement and finding that a R10, 000 co-payment must be paid before they’ll even book you in?

And what about sub-limits? Often a medical scheme will have sub-limits on some of the procedures. Let’s say you go in for a hip replacement. Your scheme might limit the cost of the artificial joint itself to R30, 000. So what happens when the joint costs R50, 000?

Hopefully you understand what gap cover does and why it’s so important. Now let’s look at one of the companies who operate in this market – Zestlife.

Zestlife offers two products:

  • Zestlife Universal Gap Cover, and
  • Zestlife Essential Gap Cover

In this article we take a look at their flagship product and how the Universal Medical Gap Cover product addresses each of these problems…

The cost of specialists while in hospital

Zestlife will pay up to 5 times your medical aid tariff rate for expenses generated by doctors and specialists while you’re admitted to hospital.
So if for example, your medical aid is prepared to pay R1, 000 for a procedure (Known as the medical tariff rate), then  Zestlife is prepared to pay the difference between this and what the specialist charges at the medical tariff rate, limited to 500% of your medical tariff rate. In other words, R5, 000.

On top of this, Zestlife will pay up to 5 times the medical tariff rate for outpatient treatment of around 50 procedures. This includes the cost of MRI, CT, and PET scans. Remember that Zestlife pays the difference between what your medical scheme is willing to pay, and what your doctor is charging, but limited to the 500% of the tariff rate.

What’s nice is that Zestlife includes in-hospital dentistry here as well.


Full cover for co-payments
If the co-payment is R2, 000 Zestlife pays it. If the co-payment is R100, 000, Zestlife pays it.

Sub limits for internal prosthesis and artificial joints

R30, 000 per year per policy
Remember the hip joint problem mentioned above; the joint costs R50, 000 but your medical aid scheme is only prepared to pay R20, 000? This section takes care of that.

Co-payments for non-networked hospitals

So you’re on a medical plan which requires you to make use of certain hospitals otherwise pay a penalty. Problem is that your specialist doesn’t operate at this hospital, so what now? You can either find a new specialist or pay the penalty. Zestlife will pay R8, 600 per year as a once off amount towards that penalty.

Co-payments for cancer treatments

Quite probably your medical scheme has an annual amount available as an oncology benefit. Often, when you breach that limit, an excess needs to be paid for any further benefits. Usually this excess is equal to 20% of each and every subsequent treatment.

Zestlife will pay up to 20% of the excess once you’ve run through your annual oncology benefit.

So what happens if you were diagnosed with cancer prior to joining Zestlife?
Well it all depends on when. No benefits are payable for:

  • 12 months from the day you start your policy
  • in respect of conditions
  • for which in the 12 months before starting the policy,
  • you had received treatment or advice

Sounds simple enough.

And then there are the benefits we haven’t as yet mentioned

Things like:

  • Enhanced cancer cover which pays R25, 000 as a lumpsum in the event of first time diagnosis of stage 2 cancer. This excludes skin cancer and only applies to cancer diagnosed after your Zestlife policy starts and after the 12 month waiting period ends.
  • Enhanced Cancer cover: Cosmetic Breast Reconstruction which pays up to R20, 000 towards the costs of the reconstruction of the non-affected breast when a single mastectomy occurs. It’s quite possible that your medical aid will consider this to be cosmetic surgery, in which case they won’t pay.
  • Emergency room cover pays up to R10, 000 for casualty visits caused by accidents. This has been raised from the R5, 000 available in 2017. Remember that casualty visits aren’t paid from your hospital benefit. Usually they get paid from your medical savings account – or if there’s no money left – from your pocket.
  • Accidental dentistry cover of up to R15, 750 paid per person if a tooth is fractured because of a blow to the head (Boxers take note!). Basically you’re covered for R2, 250 per tooth even if the medical aid has already paid for treatment.
  • Accidental death and accidental permanent disability cover pays R50, 000 as a lumpsum. The accidental disability cover falls away at 65.
  • Trauma counselling covered at R750 per session with an annual limit of R25, 000.
  • Medical aid and medical gap cover costs paid at up to R6, 500 a month for 3 months in the event of death or permanent disability of the policyholder. This benefit falls away when the policyholder turns 65.

So how much will it cost in 2018?

The good news is that Zestlife treats everyone differently.
“Why?” you may ask. Well why should a single young person pay the same as someone who is older or who has a family?

  • A single person – younger than 55 – pays R324 a month.
  • A single person – older than 55 but younger than 65 – pays R409 a month. This is new for 2018.
  • A single person – 65 and older – pays R466 a month.
  • A family pays R409 a month where everyone on the plan is younger than 65 and R466 a month when one of the family members on the plan is older than 65.

Zestlife has also thrown in a few optional extras which you might be interested in:

Extended lump sum cancer cover

This pays out upon the first time diagnosis of cancer. It excludes skin cancer, has a 12 month waiting period for pre-existing conditions, and a 6 month waiting period from starting the policy. It falls away when the insured turns 65.

  • R75, 000 at a cost of R68 a month
  • R175, 000 at a cost of R130 a month

Extended dentistry cover

Optional lumpsum cover for emergency, accidental and specialised dentistry. The amount paid out depends on the exact treatment. Once again, a 12 month pre-existing condition waiting period and a 6 month general waiting period from start of policy. Cover falls away at 65.

  • R259 a month

Medical Premium Waiver

This takes care of your medical aid and Zestlife costs upon death or permanent disability of the payer. A maximum of R6, 500 a month will be paid in addition to the 3 months free cover already mentioned above. Maximum start age is 60 and cover falls away at 65. Once again, a 12 month pre-existing condition waiting period will apply. Also be aware of the general exclusions such as suicide, self-inflicted injury, participation in war and crime, the usual stuff.

  • 24 months cover – R165 a month
  • 60 months cover – R289 a month

InsuranceFundi has partnered with some of SA’s most reputable insurance and investment companies. We believe that everyone should have access to a wide range of comprehensive and affordable solutions. Pick the product you are interested in below, and expect a call-back from our partners.

Until next time.

The InsuranceFundi Team