You book a doctor’s appointment thinking it’ll be a quick check-up. Then you’re referred to a specialist. The specialist wants a scan. Before you know it, there’s a procedure on the table and a whole lot of medical jargon coming your way.
It can happen quickly.
While you can’t always predict when you’ll need medical treatment, understanding where unexpected medical costs can come from can help you feel a little more prepared if a simple doctor’s visit turns into something more.
It doesn’t always end at a doctor’s visit
Sometimes, your GP can diagnose the problem, prescribe treatment and send you on your way.
Other times, they may need a little more information.
You could be referred to a specialist, sent for additional tests or told that you need a procedure. Depending on what’s wrong, this could eventually lead to treatment in hospital.
Suddenly, you’re dealing with more than the original reason you booked the appointment.
And while your first thought is understandably your health, there’s another question that often comes up: What is my medical aid actually going to pay?
Understand the importance of regular check-ups.
Having medical aid doesn’t always mean everything is paid in full
This is where things can get confusing.
What starts as a simple doctor’s visit can sometimes lead to further tests, specialist care or even a hospital procedure. You have medical aid, so you may assume that everything will simply be covered. But the amount charged by a healthcare provider and the amount your medical scheme pays aren’t always the same.
For example, a specialist could charge more than your medical scheme’s rate for an eligible in-hospital procedure. Depending on your medical scheme and treatment, you could also face certain co-payments.
The amount left for you to pay can become an unexpected medical cost you didn’t necessarily budget for.
And when you’re already dealing with an illness, injury or upcoming procedure, an unexpected bill is probably the last thing you want to worry about.
How do medical expense shortfalls happen?
Let’s say you need an eligible procedure in hospital.
Your medical scheme agrees to cover the procedure according to its rules and rates. However, the specialist performing the procedure charges more than the amount your medical scheme pays.
That difference is known as a medical expense shortfall.
It doesn’t necessarily mean your medical aid hasn’t paid. It means there can be a difference between what the provider charges and what your scheme covers.
Depending on your medical scheme, procedure and chosen providers, these differences can leave you with an amount to pay yourself.
Discover ways to avoid medical shortfalls.
Then there are co-payments
A shortfall isn’t the only unexpected medical cost you could encounter after a doctor’s visit.
Your medical scheme may require you to pay a portion of the cost of certain eligible procedures or treatments yourself. This is commonly known as a co-payment.
If your doctor’s visit leads to further treatment and you haven’t checked your medical scheme benefits beforehand, finding out that you need to contribute towards a procedure can come as a surprise.
This is why it’s worth understanding how your medical aid works before you’re sitting in a hospital gown trying to figure it all out.
Before a planned procedure, ask questions
If a doctor’s visit leads to a planned procedure, use the time beforehand to understand what you could be responsible for paying.
Ask your medical scheme whether the procedure is covered and whether any co-payments apply. Find out which rates they pay and whether there are specific hospitals or providers you need to use.
You can also request quotes from your healthcare providers and compare these with what your medical scheme has authorised.
A few questions beforehand could give you a much clearer picture of what to expect financially.
Where does Gap Cover come in?
Gap Cover is designed to work alongside your medical aid, especially when a doctor’s visit leads to further treatment or an eligible hospital procedure.
Depending on your plan and the circumstances of your claim, it can help cover certain eligible medical expense shortfalls and co-payments.
Think of your medical aid as your primary cover and Gap Cover as an additional layer of financial protection for certain costs your medical scheme may not pay in full.
It’s important to remember that Gap Cover isn’t a replacement for medical aid. You need an active medical aid for Gap Cover.
Why think about Gap Cover before you need it?
Because the best time to understand your cover isn’t when you’ve just been told you need a procedure.
Gap Cover policies can have waiting periods, benefit limits, exclusions and other conditions. Taking out cover after discovering you need treatment doesn’t mean that treatment will automatically be covered.
Having the conversation earlier means you can understand what protection you have in place before an unexpected medical event happens.
It also gives you time to read your policy documents, understand your benefits and know how the claims process works.
A little preparation can go a long way
You can’t plan every doctor’s appointment, diagnosis or hospital stay.
What you can do is understand your medical aid, ask questions about your treatment costs and know where you could potentially face a shortfall.
And if you want an additional layer of protection against certain unexpected medical costs, Gap Cover may be worth considering.
Oneplan Gap Cover works alongside your medical aid and can help towards certain eligible in-hospital medical expense shortfalls and co-payments.*
Because dealing with an unexpected medical situation is enough. An unexpected bill doesn’t need to make it harder.
Your Gap Cover Family,