understanding-medical-cover Understanding medical cover

Most of us experience medical cover as our second-highest monthly expense. Martin Neethling, Business Head at Sanlam Healthcare Consultants, says in spite of this, many people still end up shouldering significant shortfalls when admitted to hospital or requiring expensive out-of-hospital treatment.

With all the products and providers to choose from, all with complex information and confusing terms of cover, he recommends an annual review of medical cover options with a health-accredited financial planner to ensure that your benefits match your and your family’s health needs and current financial state.

What’s the danger of not reviewing my medical scheme cover? You may assume you’re covered only to discover that you’re facing a large shortfall in what your medical scheme will contribute to your hospitalisation and specialist treatment. We know that specialist treatment accounts for the biggest part of medical costs, so the onus is on you to understand what rates specialists and hospitals negotiate on an individual basis with different medical schemes. Everyone’s medical needs differ. It is therefore important to opt for medical cover which specifically suits your circumstances and pocket and can adapt to your changing healthcare needs.

Why do you need to consider multiple providers to cover your healthcare needs? South African demarcation regulations prevent medical schemes from selling both gap cover and hospital cash plans. Medical schemes are regulated by the Council of Medical Schemes, whereas the likes of gap cover and hospital cash plans are governed by the Long-term and Short-term Insurance Acts. So, each of the products that you may need to cover all your healthcare needs has their own rules, benefits and regulations. Some healthcare providers, like Sanlam Healthcare Consultants, can facilitate the entire package – from advice on healthcare and medical scheme options, to gap cover.

What are the “must-have” health products? It will depend on your healthcare needs and your ability to afford them. A comprehensive option is often desirable, but depending on your unique needs you may decide to shift extensive formularies and prosthesis benefits, dentistry, optometry or specialised cosmetic interventions further down on your healthcare menu.

• Primary healthcare insurance, which allows you access to a wide range of medical service providers, who will take care of your day-to-day healthcare needs. This access may limit the risk of hospitalisation and chronic diseases.
• Gap cover, which provides a ‘top up’ to cover the difference between what medical service providers may charge and what the medical scheme pays when you are admitted to hospital.

What am I paying for that I don’t need? Some people register the whole family on the most expensive option as a comfort blanket for the “what ifs”, meaning they could be paying for benefits they don’t really need. This, once again, highlights the need for an annual review of your medical cover. It may be more beneficial to register family members with higher healthcare needs on a separate plan, so that the entire family doesn’t end up paying more for benefits only needed by some. Speak to your healthcare adviser to find the best options for your individual needs.