The escalating costs of healthcare have become a pressing concern for individuals and families worldwide. Even with comprehensive medical aid, unexpected medical bills can impose significant financial strain. Recognizing this challenge, Discovery Health has introduced Gap Cover—a cost-effective insurance product meticulously designed to bridge the gap between the rates charged by healthcare professionals and the amounts covered by medical schemes. This article delves into the features, benefits, pricing, and considerations of Discovery Gap Cover in 2024.
Understanding Discovery Gap Cover
Discovery Gap Cover is a supplemental insurance product tailored to complement existing medical aid plans. Its primary purpose is to cover the shortfall between the rates charged by medical professionals and the amounts reimbursed by medical schemes. For instance, if a medical procedure costs more than the rate your medical scheme covers, Discovery Gap Cover steps in to pay the difference, ensuring you’re not left out-of-pocket.
Regulated by the Financial Sector Conduct Authority (FSCA), Gap Cover is a vital tool in safeguarding individuals and families from unexpected medical expenses that surpass their medical aid’s coverage limits.
Features of Discovery Gap Cover in 2024
Discovery Gap Cover has been reimagined in 2024 to offer comprehensive protection against unforeseen medical costs. Here’s a breakdown of its standout features:
1. In-Hospital Specialist Gap Cover
- Coverage: Pays up to 500% of the medical scheme rate on the Comprehensive option and up to 250% on the Core option when approved in-hospital specialist claims exceed medical scheme payouts.
- Scope: Includes dental specialist claims funded by the scheme’s hospital benefit.
2. Hospital Admission Benefit Extender
- Additional Coverage: On the Comprehensive option, you receive up to R15,000 extra gap cover per policy for:
- Remaining shortfalls on approved in-hospital specialist claims.
- Specified out-of-hospital expenses related to authorized hospital admissions.
- Private ward cover for approved hospital admissions (subject to hospital availability and limited to five nights per person annually).
- On the Core option: Up to R7,500 extra gap cover per policy to address additional gaps beyond the In-Hospital Specialist Gap Cover.
3. Oncology Benefit Extender
- Coverage Limits: Up to R100,000 per person annually on the Comprehensive option and up to R75,000 on the Core option for shortfalls on approved cancer-related claims post reaching the medical scheme’s oncology threshold.
4. Scopes and Scans Benefit Extender
(Exclusive to Comprehensive Option)
- Coverage: Addresses co-payments and deductibles for:
- MRI and CT scans conducted out-of-hospital.
- Endoscopies (gastroscopy, sigmoidoscopy, proctoscopy, and colonoscopy) performed in-hospital.
5. Travel Benefit Extender
(Exclusive to Comprehensive Option)
- International Coverage: Covers shortfalls on approved emergency medical claims incurred during travel outside South Africa, including deductibles on emergency out-of-hospital claims and the Cleveland MyClinic second opinion consultation fee.
6. Hassle-Free Claims Process
- Seamless Processing: No separate claim submissions required. Discovery automatically identifies, assesses, and pays gaps once the medical scheme processes the claim.
Pricing Structure
The fees for Discovery Gap Cover in 2024 are structured based on the chosen coverage level (Comprehensive or Core), the medical scheme plan, the age of the oldest member on the plan, and the family structure. Here’s a general overview:
Discovery Gap Comprehensive
| Age at Entry | Executive & Classic Plans | Essential Plans | Coastal Plans |
|---|---|---|---|
| Single / Family | Single / Family | Single / Family | |
| 0 – 54 | R226 / R382 | R426 / R973 | R426 / R973 |
| 55 – 64 | R382 / R583 | R780 / R1,486 | R780 / R1,486 |
| 65+ | R490 / R809 | R1,036 / R1,954 | R1,036 / R1,954 |
Discovery Gap Core
| Age at Entry | Executive & Classic Plans | Essential Plans | Coastal Plans |
|---|---|---|---|
| Single / Family | Single / Family | Single / Family | |
| 0 – 54 | R143 / R260 | R272 / R610 | R272 / R610 |
| 55 – 64 | R260 / R390 | R497 / R946 | R497 / R946 |
| 65+ | R334 / R543 | R660 / R1,244 | R660 / R1,244 |
Note: These premiums are subject to change and may vary based on individual circumstances. While Gap Cover represents an additional expense, it’s often significantly less than the potential out-of-pocket costs from private medical treatments, making it a worthwhile investment for many.
Advantages of Discovery Gap Cover
- Financial Protection: The primary benefit is safeguarding against medical bills that exceed medical scheme rates. This protection ensures individuals and families aren’t burdened with unexpected medical expenses.
- Comprehensive Coverage: From in-hospital procedures to out-of-hospital scans, and even international emergency treatments, Discovery Gap Cover offers extensive protection.
- Oncology Support: With substantial coverage for cancer-related treatments, policyholders receive crucial support during challenging times.
- Hassle-Free Claims: The automatic identification and processing of claims eliminate administrative burdens, ensuring a smooth experience.
- Affordable Premiums: Given the breadth of coverage, the premiums are competitively priced, offering value for money.
- Flexibility: With options like Comprehensive and Core, individuals can choose coverage levels that align with their needs and budgets.
Disadvantages and Considerations
- Additional Cost: Despite its benefits, Gap Cover represents an extra monthly expense on top of existing medical aid premiums, which can strain budgets, especially for those already facing financial challenges.
- Exclusions and Waiting Periods: Not all medical procedures are covered. For instance, there’s a three-month general waiting period for all healthcare services (except authorized emergency hospital admissions) and a 12-month waiting period for certain treatments like pregnancy-related services, joint replacements, and scopes.
- Eligibility Restrictions: Only members of the Discovery Health Medical Scheme (excluding KeyCare plans) qualify. Downgrading to a KeyCare plan results in policy cancellation.
- Complexity: Understanding the nuances between the Comprehensive and Core options, along with the various benefit extenders, can be challenging for some.
Eligibility and Exclusions
Eligibility
- Medical Scheme Membership: Only members of the Discovery Health Medical Scheme are eligible for Discovery Gap Cover. KeyCare plans are excluded. If you downgrade your health plan to a KeyCare plan, your Gap Cover policy will be canceled.
Exclusions
Discovery Gap Cover policies do not cover:
- Claims excluded by your medical scheme plan.
- Claims where the hospital admission wasn’t approved by your medical scheme without an authorization number.
- Claims not processed, approved, or covered by your medical scheme for reasons like plan deductibles (except specific exceptions), exceeding plan limits, or unrecognized claims.
- Out-of-hospital claims unless specified.
- Oncology-related co-payments part of innovative cancer treatments related to the scheme’s Oncology Innovation Benefit.
- Claims exceeding the overall annual limit of R198,000 per person.
- Claims related to weight-loss surgery.
- Claims from healthcare services not provided by appropriately registered specialists (with specific exceptions).
- Claims incurred outside South Africa or charged in foreign currency, except those qualifying under the Travel Benefit Extender.
- Shortfalls on the scheme’s Overseas Treatment Benefit claims.
- Out-of-pocket payments not covered by the medical scheme, such as deductibles, exclusions, and amounts claimed above health plan benefit limits (with specific exceptions).
Waiting Periods
- General Waiting Period: Automatic three-month waiting period for all healthcare services, except authorized emergency hospital admissions.
- Specific Treatments: Automatic 12-month waiting period for treatments related to pregnancy and childbirth, endometrial ablations, hysterectomy, joint replacements, scopes, cataracts, cholecystectomy, wisdom teeth, orthognathic surgery, dental implants, tonsillectomy, grommets, adenoidectomy, nasal procedures, hernia procedures, and reflux surgery.
- Pre-existing Conditions: If you or any dependents have a pre-existing medical condition upon application or upgrading, claims related to this condition are excluded for the first 12 months.
- Previous Gap Cover: If you’ve had gap cover with another insurer for at least six consecutive months with less than a 90-day break before activating with Discovery, certain waiting periods may not apply.
Conclusion
In an era where healthcare costs continue to rise, having a safety net like Discovery Gap Cover is invaluable. It offers comprehensive protection against unforeseen medical expenses, ensuring individuals and families aren’t caught off guard. While it does come with additional costs and certain limitations, the peace of mind and financial security it provides often outweigh these concerns.
Before making a decision, it’s imperative to assess individual healthcare needs, financial situations, and understand the specific terms, exclusions, and waiting periods associated with the policy. By doing so, one can make an informed choice that best aligns with their circumstances.
Frequently Asked Questions (FAQs)
1. What is the overall annual limit for Discovery Gap Cover?
The overall annual limit for Discovery Gap Cover is R198,000 per person.
2. Can I upgrade or downgrade my Discovery Gap Cover option?
Yes, you can downgrade from Discovery Gap Comprehensive to the Core option at any time with 30 days’ notice. Upgrading from Core to Comprehensive is also possible with 30 days’ notice, but underwriting may apply.
3. Are there any waiting periods for specific treatments?
Yes, there’s a three-month general waiting period for all healthcare services (except authorized emergency hospital admissions) and a 12-month waiting period for certain treatments like pregnancy-related services, joint replacements, and scopes.
4. Does Discovery Gap Cover apply to international medical claims?
On the Comprehensive option, the Travel Benefit Extender covers shortfalls on approved emergency medical claims incurred while traveling outside South Africa, including deductibles on emergency out-of-hospital claims.
5. How are claims processed with Discovery Gap Cover?
Discovery automatically identifies, assesses, and pays gaps once the medical scheme processes the claim, eliminating the need for separate claim submissions.