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2019

2019. ZESTLIFE GAP COVER. 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 Total claims paid R52m. Expected to be approximately

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2019

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  1. 2019 ZESTLIFE GAP COVER

  2. 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 • Total claims paid R52m. Expected to be approximately R100 m for the year • Average claim amount R7 000 • Average claims received each month 1377 • 73% of claims are paid 27% repudiated

  3. 2018 THE YEAR THAT WAS • copy 1 • copy 2 • copy 3

  4. BENEFIT ENHANCEMENTS AND PREMIUM INCREASE Universal option • A few wording changes to clarify discrepancies • Overall maximum increased from R150 000 to R160 000 • Cancer lump sum increased from R25 000 to R30 000 • Casualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accident • Premium waiver maximum R6 500 to R7 300 • Dentistry maximum R15 750 to R19 250 • DSP co-payment R8 600 to R9 300 • Premium waiver limited to accident (legal requirement) but period increased from 3 to 12 months • Robotic procedures are covered up to R30 000 • Procedures in day clinics are covered • Oncology co-payment maximum increased from 20% to 25%

  5. BENEFIT ENHANCEMENTS AND PREMIUM INCREASE Universal option • New Oncology Benefit Medical Aid Cancer Cover Limit Extender • Where 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.

  6. BENEFIT ENHANCEMENTS AND PREMIUM INCREASE Essential option • A few wording changes to clarify discrepancies • Casualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accident • Robotic procedures are covered up to R30 000 • Procedures in day clinics are covered • Overall maximum increased from R150 000 to R160 000

  7. ZESTLIFE ESSENTIAL GAP COVER MEDICAL EXPENSE SHORTFALL Limited to twice the Medical Scheme payment Accidental death and accidental permanent disability R50 000 HEALTH INSURANCE BENEFITS List of Out-patient procedures including MRI scans Trauma counselling R750 per session R25 000 per year Co-payment cover Casualty cover R20 000 Robotic machinery cover R30 000 NEW

  8. ZESTLIFE UNIVERSAL GAP COVER Limited to 5 TIMES TARIFF Non DSP co- payments up to R9 300 limited to 1 claim per policy Accidental death and accidental permanent disability R50 000 MEDICAL EXPENSE SHORTFALL HEALTH INSURANCE BENEFITS List of Out-patient procedures including MRI scans 25% oncology co-payment Trauma counselling R750 per session R25 000 per year Co-payment cover R20 000 Mastectomy benefit cosmetic reconstruction of non-affected breast Accidental Dentistry R19 250 Casualty cover R20 000 Cover for internal prosthesis up to R30 000 R30 000 cancer lump sum on first diagnosis In-hospital dentistry shortfall 12 month premium waiver on accidental death and disability up to R7 300 (age 65) Robotic machinery cover R30 000 20% of ongoing cancer costs after medical aid limit is reached NEW

  9. PREMIUMS 2019 Rate Discounts for groups based on number of members and average age. The discount ranges between 10% and 50%

  10. FUTURE OF GAP COVER • National Health Insurance to replace gap cover? • Who will pay for the specialist costs? • Medical aids cannot afford it on current contributions • Specialists in short supply and high demand are unlikely to reduce fees • Members cannot afford it NHI 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.’

  11. GAP IS EASY TO SELL • http://13.81.4.140:3838/Shortfall-tool/ Use the Shortfall indicator to show clients they cannot do without Gap Cover

  12. EXAMPLE OF SHORTFALL INDICATOR These are the potential shortfalls not covered by the Medical Scheme which will be covered by Zestlife subject to Policy terms and conditions.

  13. Thank You

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