LIBERTY GAP COVER 2019 - PowerPoint Presentation

LIBERTY GAP  COVER  2019
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Slide1

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

THANK YOU

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LIBERTY GAP COVER 2019 - Description

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 Download Presentation

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