LIBERTY MEDICAL GAP COVER LIBERTY MEDICAL PREMIUM WAIVER

Transcription

1 LIBERTY MEDICAL GAP COVER LIBERTY MEDICAL PREMIUM WAIVER 2016

2 LIBERTY MEDICAL GAP COVER It has become common for medical specialists to charge fees that are well above the medical scheme rate. When this occurs, a self-payment gap is created for which you, the medical scheme member, become liable. Even though these self-payment gaps can be extremely costly and frequently occur, there remains a low level of awareness amongst medical scheme members as to the extent of this risk exposure. This is due in part to the mistaken belief that all medical scheme options provide complete cover for all in-hospital doctor and specialist charges. The reality is that these only provide funding up to the medical scheme s own pre-determined rate, known as the medical scheme tariff (MST). And because doctors and specialists are free to set their own charges, the MST amount funded is sometimes only a small fraction of the actual charges. Medical scheme benefits have not kept pace with specialist charges meaning that the magnitude and frequency of self-payment gaps will continue to grow. The following graph shows how the self-payment gap has grown since 2006 and this trend is expected to grow into the future Specialists charges Self-payment gaps 2020 Medical scheme members, across all schemes, can protect themselves from this growing Monthly Premium R281 per Family risk by choosing one of the three Liberty Medical Gap Cover options Medical Scheme & Gap Cover Medical Premium Waiver Accidental Death & Permanent Disability Accidental Dentistry Liberty Universal Medical Gap Cover, Liberty Standard Medical Gap Cover and Liberty Core Medical Gap Cover provide a choice of tiered benefit levels at different monthly premiums. 7 6 Casualty Ward Internal Prosthesis Monthly Premium R262 per Family Internal Prosthesis All three Liberty Medical Gap Cover options cover the main medical scheme member and their family listed as medical scheme dependants. 5 Cancer Cover Cancer Cover Monthly Premium R219 per Family This cover is available to members of all medical schemes and has no: age limits restrictions on the number of children covered medical underwriting requirements Non-DSP Hospital Co-payment Non-DSP Hospital Co-payment Non-DSP Hospital Co-payment Co-payment Co-payment Co-payment Out-patient Out-patient Out-patient MEDICAL SHORTFALLS COVERED Universal Medical Gap Cover includes benefits from 1-10, Standard Medical Gap Cover includes benefits from 1-6, while Core Medical Gap Cover includes benefits from In-hospital In-hospital In-hospital UNIVERSAL Medical Gap Cover STANDARD Medical Gap Cover CORE Medical Gap Cover

3 1. IN-HOSPITAL COVER Cover for up to 500% of the medical scheme rate (MST) for in-hospital doctor and specialist charges, e.g., GPs, specialists, surgeons, anaesthetists, radiologists, pathologists. This cover is provided without an annual maximum claim limit. The following example illustrates actual amounts paid by the medical scheme (based on MST) and Medical Gap Cover. Combined Doctor & Specialist Charges R Gap Cover Payment R Medical Scheme Payment R Gap Cover Payment Some of the many in-hospital shortfalls that have been paid. Combined Doctor & Specialist Charges Medical Scheme Payment R R R R R R R R R R R R R R R R R R Natural Child Birth Hernia Repair Cardiac Bypass Surgery Spinal Surgery Breast Cancer Surgery Medical Procedure 2. OUT-PATIENT COVER Doctor and specialist shortfalls are covered for the procedures listed below irrespective of whether they are performed in-hospital or at an out-patient facility. Cover is up to 500% of the MST without an annual maximum claim limit. MRI Magnetic Resonance Imaging PET Positron Emission Tomograph CT Scan Computer Axial Tomography Chemotherapy or radiotherapy Kidney dialysis Tonsillectomy Grommets Childbirth in a non-hospital setting Surgical biopsy of breast lump Sinus surgery, limited to: - Frontal sinus - Functional endoscopic sinus surgery - Bilateral function endoscopic sinus surgery Incision, drainage of Bartholin s cyst Marsupilisation of Bartholin s cyst Bronchoscopy Coronary angioplasty Coronary angiogram Oesophagoscopy Gastroscopy Entroscopy Colonoscopy Vasectomy Prostate biopsy Cataract removal Orchidopexy Pterygium removal Trabeculectomy Direct laryngscopy Hysteroscopy Dilatation and curettage Hernia repairs, limited to: - Inguinal hernia - Femoral hernia - Umbilical hernia - Epigastric hernia - Spigelian hernia Myringotomy Arthroscopy Carpal tunnel release Ganglion surgery Bunionectomy Needle biopsy of the liver Tubal ligation Cervical laser ablation 3. CO-PAYMENT COVER Upfront co-payments required by medical schemes from their members for hospital admissions, scans and certain surgical procedures are covered. This cover is provided without an annual maximum claim limit. Co-payment Amount R R R R 950 R Gastroscopy Hospital Admission Colonoscopy Hernia Repair Spinal Surgery Examples of Co-payments Covered

4 4. NON-DSP HOSPITAL CO-PAYMENT COVER Co-payments that are charged by medical schemes expressed in a Rand amount, as opposed to a percentage when members use a non-dsp hospital, are covered up to R8 000 per year, per policy and subject to one claim per policy per year. 5. CANCER COVER In addition to the shortfalls covered for cancer treatment and procedures in points 1, 2, 3 and 4 provided: Lump sum cancer cover - R is paid out on is not dependant on actual treatment costs. threshold. This cover is subject to a maximum co-payment of 20% in any one claim and will pay up to R per individual per year. Cosmetic breast reconstruction cover Up to R cover for surgical costs that are not covered by medical schemes for breast reconstruction of the non- 6. INTERNAL PROSTHESIS COVER Cover of up to R per policy per year is provided for shortfalls on the cost of internal prostheses. 7. CASUALTY COVER Accident-related charges incurred for in-hospital casualty fee, consultations, medications, radiology and pathology associated with admission to a registered hospital s casualty facility due to an accident. Where a full in-hospital admission follows casualty ward treatment, only the shortfall amount not covered by the medical scheme will be covered. 8. DENTAL COVER irrespective of cover provided by the medical scheme. 9. ACCIDENTAL DEATH AND PERMANENT DISABILITY COVER Emergency transportation / search and rescue maximum of R If as a result of an accident you are in danger of being injured or you have been injured, we will pay the related costs and expenses up to R (for each and every claim) for your necessary emergency transportation or for your search and rescue, including freeing and bringing you to a place of safety. We will not pay these costs in the case where injuries are not as a result of an accident or if the accident is unlikely to result in an injury to you. Life support equipment maximum of R If as a result of an accident, life support machinery, equipment or apparatus is needed, we will pay for the costs and expenses to hire these items up to R (for each and every claim). Trauma counselling up to R750 per visit, with an annual limit of R If you are subjected to, or are a witness of, an act of violence or a traumatic accident, we will refund you for counselling fees paid by you as a result of the violence or traumatic accident. An act of violence includes events such as murder, assault, robbery, rape, kidnapping or hijacking, which is reported to the police and for which you have a case number. The maximum that we will pay under this benefit is R750 per counselling session, up to R per policy per year. Accidental death, permanent disability, emergency transportation, life support equipment and trauma counselling cover, as outlined above, applies to all individuals insured under the policy up to age MEDICAL SCHEME AND GAP COVER MEDICAL PREMIUM WAIVER disability. This cover is subject to the policyholder having not reached the age of 65 and a maximum payment of R5 600 per month, for three consecutive months.

5 OPTIONAL CLAIM EXCESS Policyholders can reduce their monthly premium by choosing to apply a R1 500 claims excess to their policy. When applied, in-hospital, out-patient, co-payment and sub-limit benefits will only be covered for the amount exceeding R Monthly premiums with claims excess applied Medical Gap Cover option Monthly premium without claim excess Monthly premium with claim excess Universal R281 R248 Standard R262 R230 Core R219 R195 IMPORTANT POLICY TERMS AND CONDITIONS These apply to all three Liberty Medical Gap Cover policy types Universal, Standard and Core. WAITING PERIODS No general waiting period applies. This means that valid claims for procedures that are not defined as pre-existing or are related to childbirth or listed as condition-specific will be covered from the outset. PRE-EXISTING CONDITIONS In the first 12 months, no cover will be provided for treatment of conditions that existed in the 12 months prior to the policy commencement date. Previously diagnosed cancer will be regarded as a pre-existing condition unless it has been in remission for at least 5 years. This pre-existing condition exclusion applies to all medical conditions including those where waiting periods are applied. CHILDBIRTH No cover will be provided for childbirth claims for the first 10 months of cover. CONDITION-SPECIFIC PROCEDURES For the procedures listed below, no cover will be provided for the first 6 months of cover, and from months 7-12, only 50% of the normal cover will be provided. After month 12, full cover will be provided. Joint replacements Arthroscopic procedures Spinal surgery including spinal fusion Nasal surgery including sinus surgery Cardiac surgery Cataract surgery Tonsil and adenoid surgery Grommet insertion Hysterectomy Dentistry Hernia repairs These waiting periods may be waived in circumstances where treatment is required due to accident or injury after the commencement of cover. Or, in the case where a hysterectomy, tonsillectomy or adenoidectomy is required following the diagnosis of cancer, after the commencement of cover. Or, in the case of cardiac treatment arising from an event or incident occurring and/or being diagnosed after policy commencement. GENERAL EXCLUSIONS Nuclear weapons or nuclear or ionizing radiation. Suicide, attempted suicide or intentional self-injury. The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a registered medical practitioner (other than the insured person), or any illness caused by the use of alcohol. Illegal behaviour, or as a result of breaking the law of the Republic of South Africa. Participation in war, terrorist activity, invasion, rebellion, active military duty, police duty, police reservist duty, civil commotion, labour disturbances, riot, strike or the activities of locked out workers. Aviation except on a commercial flight as a fare-paying passenger. Any form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle vessel, craft or aircraft). SPECIFIC EXCLUSIONS No benefits are payable for: Cosmetic surgery Treatment for obesity Claims not covered by your medical scheme Cancer treatment outside of the borders of South Africa Private and home nursing Hospital charges Medication and other materials External prosthesis

6 OPTIONAL EXTRA COVER Cancer and dentistry are the two areas where medical scheme members face the most substantial risk of treatment funding shortfalls. Liberty Medical Gap Cover options. EXTENDED CANCER COVER This offers an optional lump sum policy benefit of either R or R , payable in the event of first-time diagnosis of cancer which covers the policyholder and all medical scheme dependants. This cover is available up to age 65 and can be added to either of the three Liberty Medical Gap Cover policy options. R Lump sum pay-out on first-time cancer diagnosis R R R R R0 Embedded Cover R Core Universal & Standard Core + R R R Embedded Cover R Universal & Standard + R R Core + R R Embedded Cover R Universal & Standard + R To qualify for the Extended Cancer Cover, policyholders are required to answer an underwriting question relating to previous diagnosis or treatment of cancer. This cover has a termination age of 65 and a 6-month waiting period from the date of application. Cancer Cover R Cancer Cover R Monthly premium without claim excess R48 R90 EXTENDED DENTISTRY COVER Extended Dentistry Cover offers optional lump sum cover for emergency, accidental and specialised dentistry and can be added to all three Liberty Medical Gap Cover options. This cover insures the policyholder and their medical scheme dependants for all the conditions listed in the first column of the table below. The middle column lists the treatment that may be required while the third column lists the fixed pay out for the insured conditions. Insured condition or event Likely treatment Cover Impacted wisdom tooth (teeth in the process of eruption that are not impacted are excluded) Periodontitis (severe infection of the gums where the attachment of the tooth to the gum is broken down) Surgical tooth removal Gum surgery R1 000 per tooth R1 500 per event Jaw fracture Surgery R per event Dental emergency (dental pain or infection that requires immediate treatment for relief) Accidental tooth fracture (50% of the visible tooth is lost due to an accident resulting in permanent nerve damage) Severely decayed or damaged tooth (two thirds of the tooth is lost due to decay or trauma) Impaired chewing due to loss of tooth/teeth (teeth can be lost due to infection or trauma, 2nd and 3rd molar positions are excluded) Reduced dental stability due to tooth loss (tooth is lost resulting in adjacent teeth potentially changing position causing the bite to become unstable) Emergency root canal, temporary Crown, splinting, bridge Crown Removable denture Implant or bridge R1 000 per event R4 000 per tooth R3 000 per tooth (A maximum of 2 teeth are covered in 12 months) R5 000 per jaw (Paid once per upper or lower jaw per 24 months) R per tooth Limited to one claim in 12 months

7 Following a 6-month upfront waiting period, cover is provided to the policyholder and their medical scheme dependants subject to a 12-month pre-existing condition exclusion up to the age of 65. Dentistry Monthly premium R238 LIBERTY MEDICAL PREMIUM WAIVER The Liberty Medical Premium Waiver policy provides the policyholder with the assurance that their medical scheme contributions and medical Gap cover premiums will be paid in the event of their death or permanent disability. The cover is paid up to a maximum of R5 600 per month, for a period of either 24 or 60 months. This cover is available to all policyholders up to age 60. EXCLUSIONS In the first 12 months, no cover will be provided should a claim arise from a medical condition that existed in the 12 months prior to the policy commencement date. The policy also applies general exclusions, e.g., claims resulting from suicide, intentional self-inflicted injury or participation in acts of war or crime. In the case of a permanent disability claim, the benefit will be paid after a 30-day assessment period and will be paid for the insured period or until the policyholder s recovery, whichever occurs first. Medical Premium Waiver Cover period Monthly premium 24 Months R Months R252 ABOUT LIBERTY HEALTH At Liberty Health we recognise that your health is your greatest you from unplanned expenses. Because no single provider can meet the needs of today s diverse healthcare markets; we bring solution for you. We deliver a range of healthcare solutions for a variety of needs. These include medical cover and risk products that complement and supplement any medical scheme cover because we know that with the increasing cost of healthcare, very few people inevitably go wrong. Our clients are people just like you: people who want us to make medical cover manageable and to help them make the most of their health. If you are looking for a healthcare solution for your needs with the least amount of hassle, we invite you to get in touch with us or speak to your Financial Adviser about us. You lead a busy life and healthcare can be very complicated. This is the last thing you need, especially when you or your family are unwell. Our business is built around providing you with the best products, administration and service in your hour of greatest need. We believe partnerships are an essential ingredient for excellence. Situated in South Africa and in 15 other countries across Africa, our business partnerships and services span medical schemes, information technology systems, employee wellness programmes, medical risk management and healthcare administration. The insights we have from being involved in multiple aspects of the healthcare industry enable us to provide you with the best solutions. WHAT WE OFFER YOU Easy to understand, affordable medical cover that is also sustainable over the long term A solution that suits your individual needs Quality healthcare solutions and medical insurance to protect you and your family when things go wrong CONTACT US For expert advice, please contact your Liberty Adviser or call us on (021) or info@zestlife.co.za LEGAL INFORMATION AND DISCLAIMER Liberty Medical Gap Cover is underwritten by Guardrisk Insurance Company Limited (FSP number 75). Liberty Medical Premium Waiver is underwritten by Guardrisk Life Limited (FSP number 76) (collectively referred to as Guardrisk ). Both products are administered by Zest Life Investments (Pty) Ltd, an authorised Financial Services Provider (FSP number 37485). This information is protected by applicable intellectual property laws and cannot be copied, distributed or modified for commercial purposes. The information contained herein is of a factual nature only and does not constitute financial advice by Guardrisk or Liberty Health as contemplated in terms of the Financial Advisory and Intermediary Services Act Any use of this information by any third party shall be entirely at the third party s discretion and is of a factual nature only. Guardrisk and Liberty Health do not express or by implication represent, recommend or propose that products or services referred to herein are appropriate to the particular needs of any third party.

8 Liberty Health Holdings Liberty Building, Estuary Precinct, Century Boulevard, Century City, 7441 t: +27 (0) f: +27 (0) e: w: Liberty Health Holdings an Authorised Financial Services Provider in terms of the FAIS Act (licence no ) Reg. No. 2007/022498/07 Liberty Health Holdings is a subsidiary of Liberty Holdings Limited. Gap Cover and Premium Waiver 2016: V10_