I’ve identified the following issues with Medical Cover that you should be weary of when buying Medical Cover.
In fact, your current Medical Cover may have these issue and you don’t know because you’ve not read your policy wording or don’t understand your Benefit Table.
ISSUE 1) Low Overall Global Limits and Sub limits for Hospital Bills
Some Health Insurers are reasonably good at paying out day-to-day out-patient medical expenses. But they fail miserably when it comes to their Sub Limits and their overall Global Limit. i.e. the total amount you can claim in a single year.
Low overall global limits and sub limits pertaining to hospitalisations are possibly the biggest problem with the majority of medical plans and the main reason why members end up in horrendous debt due to medical bills.
During my research, I discovered that it’s not uncommon to see hospital related medical bills running into hundreds of thousands of US dollars.
The highest medical bills usually result from Multiple Body Trauma and Burns. Multiple body trauma due to vehicle accidents seem to attract the largest bills.
In fact, Mediclinc in South Africa told me the following in 2016: “Mediclinic does experience cases which are in excess of R1million (US$150,000). These are likely in serious motor vehicle accidents, premature babies requiring neonatal specialised facilities etc.”
That was back in 2016 so it has definitely gone up since then.
During my research, I also discovered that some of the most popular medical plans’ overall limits that are available in Africa don’t even exceed US$100,000 let alone US$500,000. US$500,000, in my opinion, is the bare minimum you should consider but still doesn’t guarantee that you’ll be financially okay if something serious were to happen.
What’s probably more shocking is that the majority of people I’ve spoken to don’t even know what their overall global limits and sub limits are. They only find out when it’s time for treatment or a claim but that’s when it’s too late.
Side note: Do you honestly know what your global limits and sub-limits are? Most people reading this would answer that with a “NO”. I sincerely hope you are not one of them.
I’ve also heard of some Health Insurers saying that their overall global limits are high enough and that nobody (or hardly anyone) has exceeded their overall global limit or sub limits. They’ll also say that their competitors only have a high global limit because it’s an advertising gimmick.
Well, when you look at the facts, they’re mostly right but not always.
Ask them if they will guarantee, in writing, that you’ll never exceed their Global Limit and sub-limits and see what they say!
In fact, no medical aid or medical insurance company will ever guarantee that their Global Limit is high enough! Why? Because they know how expensive medical treatment is. Doesn’t that tell you something about how important it is to have higher limits?
Recommendation: (1) Obviously be weary of those who say you shouldn’t concern yourself about their Global Limits and sub limits not being high enough.
Recommendation: (2) To minimize your greatest potential of finding yourself in debt, your medical plan should have a high overall global limit and high sub limits – especially on the Hospital section. The higher the limits the more expensive it will be but the better protected you’ll be too. Personally I prefer my limit to be around the US$500,000 – US$1,000,000 figure or higher.
ISSUE 2) Zero or Limited Air Ambulance Cover
Do you know that medical evacuation flights are largely based on distance travelled? For example, an air ambulance flight from Harare to Johannesburg can cost anything from US$11,000 – US$22,000 depending on (a) your medical condition and (b) which air ambulance aircraft is used?
The highest one I’ve seen was for US$100,000 which was from Nigeria to South Africa.
Some Health Insurance companies only pay for local air ambulance services and some have no cover at all for critical-care air evacuations.
Therefore, if your medical plan has low or restricted air ambulance cover, even though you may have been advised to be evacuated to another country for better treatment, you may be forced [financially speaking] to seek treatment locally due to the unaffordable evacuation costs.
Recommendation: As a minimum, ensure that your medical plan covers local and cross border air ambulance costs and check the limits.
ISSUE 3) Limited List of Service Providers with Direct Billing Arrangements
Some Health Insurance companies have direct billing agreements in place with only a handful of service providers. So if you seek treatment outside their approved list, you may be required to pay either upfront or at least a deposit before being treated. Also, you may only have a portion refunded – depending on what’s stated in the medical plans policy contract/wording.
This may be okay for some low cost out-patient examinations and treatment – but what will happen if you need to be hospitalized in an emergency or for elective care (none emergency treatment) and you don’t have immediate access to the necessary funds?
Recommendation: Ensure that your medical plan covers a wide range of service providers on direct billing.
ISSUE 4) Low Oncology (Cancer) Benefits or Delayed Cover for Oncology
Some medical plans either have low oncology benefits or excessively long waiting periods before they’ll pay for treatment for cancer.
Unfortunately, cancer doesn’t normally wait for medical benefits to become active before it manifests itself. And cancer treatment can be very costly especially if it reappears within the same period of cover?
When I last checked, some cancer treatment was as high as US$150,000!
Recommendation: Ensure your medical plan has a high limit for cancer treatment and that it’s covered from day one.
ISSUE 5) Medical Bills Not Paid In Full
Some medical plans do not pay all your medical bills in full.
They have what’s known as shortfalls, co-payments, deductibles or they follow a tariff system. That means, not everything being billed by the medical provider will be covered by your medical plan.
Recommendation: Ensure that your medical plan will pay your medical bills in full up to the advertised limits or up to what is known as reasonable and customary. Especially the hospital (in-patient) section.
ISSUE 6) No Cover or Limited Cover Outside Your Home Country
Some Health Insurance companies either do not pay for treatment outside your home country at all or they’ll only cover a portion of the bill.
Recommendation: With many cases now being referred outside your home country, and because in many cases it’s better to be treated regionally or internationally, ensure that treatment outside your home country is in fact covered and will be paid in full. This is known as your Area of Cover.
ISSUE 7) Pro-rata Benefits
A handful of Health Insurers have a financial year that runs from January 1 to December 31, so they pay their benefits on a pro-rata bases This can severely reduce your benefit limits if you join mid-year.
For example, if you join on, say, July 1, although you are paying the full premium, you only get 50% of the plan’s benefits until the beginning of the new financial year when your limit increases to 100% of the advertised benefits.
Recommendation: Ensure that the advertised limits are not too severely affected if you join mid year. Alternatively, join a medical plan that does not pro-rata their benefits when you join.
ISSUE 8) Low Organ Transplant Cover
Some health insurers have low benefits for organ transplants. Yet transplants can easily cost US$100,000 or more depending on complications and the type of organ you need.
Recommendation: Ensure that the Organ Transplant benefit has a reasonable max limit.
ISSUE 9) Low Intensive Care or Low High Care Cover
In many cases, intensive care or high care costs make up the majority of the hospital bill. For example, my mothers ICU cost was US$5,000 per day – in 2016!!!
Recommendation: Ensure that the intensive care and high care benefit has a very high max limit.
ISSUE 10) Does Not Guarantee Renewal or Restricts Benefits at Renewal Due To Past Claims
In my opinion, be very careful of health insurers who will decline cover or restrict benefits due to age or ill health at renewal. You will find it quite frustrating when looking for other cover should you wish to move.
Recommendation: Ensure that your benefits or cover will not be affected if you fall ill or get older.
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