It will help ensure that your payments are settled promptly.
By Michael Emery, Marketing Executive at Ambledown Financial Services
A recent article in the Financial Mail makes clear gap cover is becoming more prevalent. A key driver is persistent medical inflation, so the gap between what a medical scheme pays and what is charged is growing. One industry player says that monthly gap cover claims are up by R1 million compared to previous years.
Another major factor is the cost-of-living crunch, which is seeing many people opt for cheaper medical schemes with lower benefits, leading to a greater reliance on gap cover. Ambledown’s average gap claim for an insured event is R9 409.12.
Whatever the causes, gap cover has never been more important when it comes to protecting members of medical schemes from financial disaster when hospitalised or requiring specified out-patient procedures.
With that in mind, understanding how the claims process for gap cover works is essential to ensure payment is made quickly and that claims are not rejected. Here are the main points to be aware of:
Read the policy document and make sure you understand your benefits. Working with a trusted broker is an excellent way to make sure you claim for all the benefits to which you are due, and that a claim is valid. Claims will only be considered if they fall within the particular policy’s benefit structure.
One key point to remember is that if a claim is declined by the medical scheme, it is not eligible for gap cover. Gap cover is not a medical scheme, and the cover is not the same as that of a medical scheme. Gap cover is not a substitute for medical scheme membership. Other reasons for a claim not to be paid include waiting periods when a policy is signed or upgraded, or if there was a pre-existing condition as defined in the policy within the first 12 months of the contract. The duration of any waiting period can vary between policies and insurers. Some policies might waive waiting periods for certain conditions or under specific circumstances.
Submit all the right documents. Incomplete claims submissions are a common mistake. Every claim for gap cover must include:
- A fully completed and signed claim form.
- Detailed accounts from all the service providers whose shortfalls you wish to claim.
- Detailed hospital account.
- Detailed medical scheme statement.
All this detail is necessary because the gap cover covers the difference between what the medical scheme paid and what was charged for in-hospital treatment and defined out-patient treatment. If there is a co-payment as well as a gap claim, then each claim is assessed separately line by line.
Ensure the claim form is signed wherever indicated.
Submit any claim within the time limits stipulated in the policy. Typically, claims should be submitted within 180 days from the first day of treatment.
Keep up with new developments in claims. If your insurer has an app, the claim can be tracked very easily. The onward march of artificial intelligence looks set to make the claims process smoother and ultimately faster too. For example, Ambledown recently announced AmChat, a bot that will allow clients to ask basic questions and receive feedback on claims. It is particularly useful in identifying missing documentation quickly. In the future, it seems likely that digitising the claims process will free up human agents to focus on claims assessment and complex cases, making the whole process quicker. More intuitive self-service options are also in the pipeline.
Gap cover is undoubtedly playing a bigger role in financial planning and, as ever, it’s very important to understand how it works.
Ambledown Financial Services is authorised Financial Services Provider No.10287.
