This is the ideal benefit offering to choose if your medical aid has additional co-payments and out-of-pocket deductibles.
A Medical Expense Shortfall is the difference between what medical service providers (e.g. Doctors, basic and specialised Radiology, Pathology, Specialists) charge and what Medical Schemes pay for the treatment performed in hospitals and day clinics, provided that it is paid from the Hospital Benefit of your Medical Scheme.
Medical Expense Shortfall Cover will boost your Medical Aid rate, helping you with this shortfall!
Below is an example of a claim for a Hip replacement
|MEDICAL SERVICE PROVIDER||AMOUNT CHARGED BY THE MEDICAL SERVICE PROVIDER||AMOUNT PAID BY MEDICAL SCHEME||AMOUNT PAID BY TURNBERRY|
|Surgeon||R17 053||R6 021||R11 032|
|Anaesthetist||R8 256||R2 402||R5 854|
|Total paid by Turnberry||R16 886|
A co-payment or deductible is an upfront amount that needs to be paid to the hospital/day clinic /radiologist before undergoing certain procedures, as specified by your Medical Scheme
When you experience a co-payment for a procedure or scan (as specified by your Medical Scheme) you would need to pay for the co-payment up-front and then claim the amount back from your MediGap Prestige policy (provided that the plan you selected offers a co-payment benefit)
If your Medical Scheme pays for co-payments from your day to day benefits you may still claim the amount back from your MediGap Prestige policy.
Should you choose to go to a hospital or day clinic outside of your Medical Schemes Hospital Network/Designated Service Providers, you would be liable for a portion of the account,as specified by your Medical Scheme.
Johnny’s Medical Scheme stipulates that he needs to go to hospital X, if :
He chooses to go to another hospital he would need to pay the first R8 000 of the hospital account. Johnny chooses to go to hospital Y and pays the R8 000 and then claims it back from his MediGap Prestige policy
When a Medical Scheme will only pay for a certain procedure, prosthetic device or scan up to a specified limit, this is a sub-limit.
Joe gets admitted to hospital for a hip replacement. After the procedure he notices that the cost of the prosthetic hip was R60 000, but his Medical Scheme only paid R50 000 towards the prosthetic hip, leaving him liable for R10 000.
Luckily for Joe, he has a MediGap Prestige policy that offers sub-limit cover of R20 000 per admission per insured. Subject to the Overall Annual Limit
Therefore Joe can submit the account to MediGap to pay the R10 000 the difference from his MediGap Prestige Policy.
Medical expense shortfall expense
Non-dsp hospital penalty cover
Co-payment for mri, ct and pet scans
Casualty benefit (accidents only)
Medical scheme contribution waiver
Gap premium waiver
International travel cover
|Treatment date of the claims is within:||Benefits for childbirth will be capped at :|
|First 12 months of the Policy||R8 000 per event|
|13-24 months of the Policy||R12 000 per event|
|25+ months of the Policy||Subject to the Overall Annual Limit of the Policy|