New rules restrict gap-cover benefits
There is no regulation of what doctors can charge or how much your scheme should pay, leaving potentially unlimited liabilities on consumers for medical shortfalls
Short-term insurers have been offering medical scheme members policies that top up their medical scheme cancer benefits, but regulations have changed the benefits that can be offered - and your cover may change even if you have an existing policy.
Regulations under the short- and long-term insurance acts introduced changes for new policies covering health events from April 1 this year.
Existing policies will have to conform with the regulations when they are renewed. For many people this will be from January 1 next year.
A key change is that benefits on policies offering cover for shortfalls between what your doctor charges you and what your scheme pays, and any shortfalls in benefits, such as cancer benefits, are now limited to R150,000 per insured person on the policy, says Mike Settas, MD at Kaelo Xelus.
These policies will now be known as medical expense shortfall policies.
The new regulations prevent insurers from setting an entry age limit and restrict insurers to charging the same premiums to all members of an employer group or category of policyholder. Premiums can only differentiate based on whether you are over or under 65 years when you take out the policy.
Insurers can only apply the same waiting periods that medical schemes can apply before you are entitled to benefits - either a three-month general waiting period or a 12-month condition-specific waiting period.
Settas says the main concern about the new restrictions on gap-cover policies is the annual limit of R150,000 per person.
While the probability of a claim in excess of this limit is small, there have been a number of cases where this limit has been breached, and in some cases, by a long way, he says.
Kaelo Xelus has had claims from policyholders for medical shortfalls of more than R300,000 per case, which would leave the member with a substantial liability.
There is no regulation of what doctors can charge or how much your scheme should pay, leaving potentially unlimited liabilities on consumers for medical shortfalls.
Prescribed minimum benefits oblige schemes to cover treatable cancers only.
A treatable cancer is one that:
• Affects only the solid organ of origin;
• Shows no evidence of spreading to other organs (metastatic spread); and
• Has not caused incurable damage to the organ or to any other life-supporting organ.
Cancer may also be regarded as treatable if there is evidence that more than 10% of people with a similar cancer survive on the specific treatment for at least five years. Cancers that affect bodily systems and non-solid organs, such as leukaemia, lymphomas and multiple myeloma, are always covered. Palliative care or end of life are also on PMB.