2018 The year that was Specialists continued charging substantially more than medical aids Percentage of gap payment compared to medical aid was 104 Specialist shortfall represent 80 of claims ID: 751061
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LIBERTY GAP COVER 2019 Slide2
2018 The year that wasSpecialists continued charging substantially more than medical aids. Percentage of gap payment compared to medical aid was 104%Specialist shortfall represent 80% of claims Total claims paid R52m. Expected to be approximately R100m for the yearAverage claim amount R7 000Average claims received each month 1377Slide3
2018 The year that was Examples of medical procedures that are
frequently not covered in full by medical
schemes
Examples of medical expense shortfalls
paid by Liberty Gap Cover in 2018
Natural Childbirth
R17 421
Caesarean Section Childbirth
R26 828
Tonsillectomy
R 7 594
Hernia Repair
R32 237
Breast Cancer Surgery
R73 863
Knee Replacement Surgery
R49 016
Hip Replacement Surgery
R73 964
Spinal Surgery
R140 745
Cancer Treatment
R108 816
Heart Surgery
R149 913Slide4
Benefit enhancements and premium increaseUniversal optionA few wording changes to clarify discrepanciesOverall maximum increased from R150 000 to R160 000Cancer lump sum increased from R25 000 to R30 000Casualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accidentPremium waiver maximum R6 500 to R7 300 Dentistry maximum R15 750 to R19 250 DSP co-payment increased from R8 600 to R9 300Premium waiver limited to accident (legal requirement) but period increased from 3 to 12 monthsRobotic procedures are covered up to R30 000Procedures in day clinics are coveredOncology co-payment maximum increased from 20% to 25%Slide5
Benefit enhancements and premium increaseUniversal optionNew Oncology Benefit.Medical Aid Cancer Cover Limit ExtenderWhere a cancer treatment cost limit is imposed and where no further treatment is funded by the medical aid, this benefit will subsidise 20% of the of the ongoing treatment costs. This benefit can be used to cover general treatment and the costs of biological drugs and other specialised treatments.Slide6
Benefit enhancements and premium increaseEssential optionA few wording changes to clarify discrepanciesCasualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accidentRobotic procedures are covered up to R30 000Procedures in day clinics are coveredSlide7
Liberty essential gap coverLimited to twice the Medical Scheme payment
List of Out-patient procedures including MRI scans
Co-payment cover
Casualty cover
R20 000
Accidental death and accidental permanent disability R50 000
Trauma counselling R750 per session R25 000 per year
MEDICAL
EXPENSE SHORTFALL
HEALTH INSURANCE BENEFITS
Robotic machinery cover
R30 000
NEWSlide8
Liberty universal gap coverList of Out-patient procedures including MRI scans
Co-payment cover
Casualty cover
R20 000
Limited to
5 TIMES TARIFF
A
ccidental
death and accidental permanent disability R50 000
Trauma counselling R750 per session R25 000 per year
MEDICAL
EXPENSE SHORTFALL
Non DSP co- payments up to
R9 300 limited to 1 claim per policy
Cover for internal prosthesis up to R30 000
In-hospital dentistry shortfall
Accidental Dentistry R19 250
R30 000 cancer lump sum on first diagnosis
12 month premium waiver on accidental death and disability up to R7 300
(age 65)
Robotic machinery cover
R30 000
NEW
25% oncology
co-payment
R20 000 Mastectomy benefit cosmetic reconstruction of non-affected breast
20% of ongoing cancer costs after medical aid limit
is reached
HEALTH INSURANCE BENEFITSSlide9
PREMIUMS 2019 Rate Discounts for groups based on number of members and average age.
Liberty Universal Gap
Liberty Essential Gap
Cover for Individuals
2019
2018
2019
2018
Younger than 55 years old
R363
R326
R274
R247
55 – 64 years old
R458
R412
R344
R309
65 years old
R521
R470
R393
R354
Cover for Families
2019
2018
2019
2018
Where all family members are younger than 65
R458
R412
R344R309Where one of more family members are older than 65R521R470
R393R354
All commission is 20% except Universal older than 65 which is 15%Slide10
Umbrella FUND PREMIUMS 2019 Rate discount for Umbrella Fund Members is approximately 35%
Compulsory
Liberty Universal Gap
Liberty Essential Gap
Cover for Individuals
2019
2018
2019
2018
Younger than 55 years old
R199
R187
R156
R147
55 – 64 years old
R246
R232
R190
R179
65 years old
R286
R269
R222
R209
Cover for Families
2019
2018
2019
2018
Where all family members are younger than 65
R246
R232
R190R179
Where one of more family members are older than 65R286R269R222R209All commission is 20% Slide11
Voluntary
Liberty Universal Gap
Liberty Essential Gap
Cover for Individuals
2019
2018
2019
2018
Younger than 55 years old
R232
R218
R180
R169
55 – 64 years old
R294
R277
R225
R211
65 years old
R349
R328
R266
R251
Cover for Families
2019
2018
2019
2018
Where all family members are younger than 65
R294R277R225
R211Where one of more family members are older than 65
R349R328R266R251All commission is 20%
Umbrella FUND PREMIUMS 2019
Rate discount for Umbrella Fund Members is approximately 35% Slide12
Future of gap coverNational Health Insurance to replace gap cover?Who will pay for the specialist costs?Medical aids cannot afford it on current contributionsSpecialists in short supply and high demand are unlikely to reduce feesMembers cannot afford itNHI may extend PMB’s and then have a network of specialist who are prepared to perform these procedures at NHI rates but there will always be those Specialists who do not agree with this.
‘As long as the specialists continue operating in a free market and funding mechanisms are under strain, there will be a need for Gap Cover.’ Slide13
Gap is easy to sellhttp://13.81.4.140:3838/Shortfall-tool/Use the Shortfall indicator to show clients they cannot do without Gap CoverSlide14
Example of Shortfall Indicator
Specialist Shortfalls
If you do not use a Specialist who has a payment arrangement with the Medical Scheme you could be liable for approximately 70% of the Specialist fees.
Co-payments
There is up to a maximum of R10 000 co-payment for the voluntary use of a non-DSP hospital which is covered subject to 1 claim per year and a maximum of R8 000
Prosthesis
If the cost of an internal prosthesis for spinal surgery exceeds R26 500 you will be liable for this extra cost
Prosthesis
For PMB only - If the cost of an internal prosthesis for a hip and major joints exceeds
R27 900 or a knee exceeds R34 400 or other minor joints exceeds R10 700 you could be liable for this extra cost
Co-payments
R3 200 for all endoscopic investigations and
specialised
diagnostic imaging if in a private hospital
These are the potential shortfalls not covered by the Medical Scheme which will be covered by Zestlife subject to Policy terms and conditions.Slide15
Example of Shortfall IndicatorSlide16
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