We use one of our client’s maternity gap cover claims as an example to illustrate the importance of gap cover for pregnancy and childbirth related medical expenses.
Many individuals only consider gap cover once they fall pregnant or when they are ready to start with family planning. Unfortunately, gap covers (as with medical schemes) have a waiting period of 12 months before they cover any shortfalls related to medical expenses for pre-existing medical conditions or for planned medical procedures.
Therefore, it is important to have gap cover in place for at least one year before thinking of falling pregnant. It is also worth a reminder that gap cover exists solely to cover the shortfall between what your medical aid covers and the rates charged by specialists for in-hospital procedures. When these shortfalls exist, it does not mean that your medical aid plan is not comprehensive enough, but rather that specialists can charge any rate they wish. When these rates are higher than what your medical aid covers, a shortfall exists for which the patient is liable.
Case study
Our client, Mrs X, has had the following gap cover policy in place for approximately 2 years prior to falling pregnant:
Stratum Benefits Elite Option: R496 per month per family
Her gap cover covered the following categories related to maternity and childbirth expenses:
Specialist tariffs for consultations
The client preferred a female gynaecologist, most of which in the area charge higher tariffs than medical scheme rates. Usually, gap covers pay the shortfall between specialist rates and the amount covered by the medical aid for procedures while hospitalised and not for out-of-hospital consultations.
Stratum’s Elite option however, is one of few gap covers that include an “out-patient specialist consultation benefit” for maternity scans that are out of hospital. This benefit is limited to R1 300 per consultation with a maximum of 3 consultations per policy per year.
Therefore, Mrs X’s first three sonars were covered by her medical aid and gap cover as follows:
Important to note here is that the client’s pregnancy stretched from January to September. The out-patient specialist benefit is available per year, therefore, if the client’s pregnancy stretched from August to April for instance, she would have access to the same benefit starting again in January, so 6 consultations will then be covered during her pregnancy.
In addition, when you have gap cover in place it allows you the financial freedom of consulting any specialist for a specific procedure (depending on the combined rate covered by your medical aid and gap cover) without having to worry about the rate they charge. If faced with a serious operation, why would you not want to consult the best of the best?
Hospital co-payment
Since Mrs X’s doctor practised at a hospital that was not one of her network hospitals as specified by the medical aid, Mrs X was liable for a co-payment in order for the delivery to take place at the specific hospital. The co-payment amounted to R9 600, which was covered by her gap cover’s co-payment benefit. The gap cover therefore refunds the member any co-payment imposed by the medical aid for non-network hospital admissions, up to R13 000 per policy per year.
Childbirth medical expenses
For the caesarean delivery, the gynaecologist and anaesthetist charged the following specialist rates of which the shortfalls were covered by the gap cover:
The hospital and paediatrician’s bills were settled by the medical aid in full since there were no shortfalls present.
This example clearly illustrates that the client would have been responsible for an additional R28 363 of medical expenses had she not had gap cover. This amount is equal to more than 4 years of gap cover contributions.
In addition, the client’s newborn is added to the gap cover policy at no additional cost. The family premium of R496 per month remains the same, regardless of how many children dependants are added to the policy. The benefits are endless when it comes to gap cover, so ensure you have the proper policy in place well in advance before starting with family planning and inform yourself on the benefits available to you.