When your health plan cover doesn't stretch as far as you need it to go

Gap cover can step in for in-hospital procedures, and help with soaring medical costs.

- By Neesa Moodley

Medical schemes offer members pooled benefits where the funds belong to the scheme members under a nonprofit structure. South Africa, which is one of the most unequal countries in the world when it comes to income, has 71 schemes (16 open, 55 restricted) serving more than 9.1 million beneficiaries.

Medical scheme savings and self-payment accounts are intended for use to pay for day-to-day medical expenses. When the savings are depleted, the member becomes personally liable for further expenses.

Michael Emery, the marketing executive at Ambledown Financial Services, however, notes there is a common misconception that gap cover will cover any self-payment gap. "Gap cover is only applicable for in-hospital treatment or procedures and certain specified outpatient procedures," he clarifies.

Brian Harris, the director of operations at Turnberry Management Risk Solutions, points out that although medical schemes operate within set guidelines, covering services according to rates determined by the scheme, many specialists charge significantly more than these rates - up to 500% of the medical scheme rate, depending on the doctor and the procedure.