1. 2019
ZESTLIFE GAP COVER

2. 2018 THE YEAR THAT WAS
Specialists continued charging substantially more than
medical aids. Percentage of gap payment compared
to medical aid was 104%
Specialist shortfall represent 80% of claims
Total claims paid R52m. Expected to be approximately
R100 m for the year
Average claim amount R7 000
Average claims received each month 1377
73% of claims are paid 27% repudiated

3. 2018 THE YEAR THAT WAS
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4. BENEFIT ENHANCEMENTS AND PREMIUM INCREASE
Universal option
A few wording changes to clarify discrepancies
Overall maximum increased from R to R
Cancer lump sum increased from R to R30 000
Casualty benefit increased from R to R Casualty visit must be
within 48 hours of the accident
Premium waiver maximum R6 500 to R7 300
Dentistry maximum R to R19 250
DSP co-payment R8 600 to R9 300
Premium waiver limited to accident (legal requirement) but period
increased from 3 to 12 months
Robotic procedures are covered up to R30 000
Procedures in day clinics are covered
Oncology co-payment maximum increased from 20% to 25%

5. BENEFIT ENHANCEMENTS AND PREMIUM INCREASE
Universal option
New Oncology Benefit
Medical Aid Cancer Cover Limit Extender
Where a cancer treatment cost limit is imposed and where no further
treatment is funded by the medical aid, this benefit will subsidise 20% of the
of the ongoing treatment costs. This benefit can be used to cover general
treatment and the costs of biological drugs and other specialised
treatments.

6. BENEFIT ENHANCEMENTS AND PREMIUM INCREASE
Essential option
A few wording changes to clarify discrepancies
Casualty benefit increased from R to R Casualty visit must be
within 48 hours of the accident
Robotic procedures are covered up to R30 000
Procedures in day clinics are covered
Overall maximum increased from R to R

7. ZESTLIFE ESSENTIAL GAP COVER
MEDICAL
EXPENSE
SHORTFALL
HEALTH
INSURANCE
BENEFITS
Limited to twice the Medical Scheme payment
Accidental death and accidental permanent disability R50 000
List of Out-patient procedures including MRI scans
Trauma counselling R750 per session R per year
Co-payment cover
Casualty cover
R20 000
Robotic machinery cover
R30 000
NEW

8. ZESTLIFE UNIVERSAL GAP COVER
MEDICAL
EXPENSE
SHORTFALL
HEALTH
INSURANCE
BENEFITS
Limited to 5 TIMES TARIFF
Non DSP co- payments up to
R9 300 limited to 1 claim per policy
Accidental death and accidental permanent disability R50 000
List of Out-patient procedures including MRI scans
25% oncology
co-payment
Trauma counselling R750 per session R per year
Co-payment cover
R20 000 Mastectomy benefit cosmetic reconstruction of non-affected breast
Accidental Dentistry R19 250
Casualty cover
R20 000
Cover for internal prosthesis up to R30 000
R cancer lump sum on first diagnosis
Robotic machinery cover
R30 000
NEW
In-hospital dentistry shortfall
20% of ongoing cancer costs after medical aid limit
is reached
12 month premium waiver on accidental death and disability up to R7 300 (age 65)

9. Zestlife Universal Gap Zestlife Essential Gap
PREMIUMS 2019
Zestlife Universal Gap
Zestlife Essential Gap
Cover for Individuals
2019
2018
Younger than 55 years old
R363
R326
R274
R247
55 – 64 years old
R458
R412
R344
R309
65 years old
R521
R470
R393
R354
Cover for Families
Where all family members are younger than 65
Where one of more family members are older than 65
All commission is 20% except Universal older than 65 which is 15%
Rate Discounts for groups based on number of members and average age.
The discount ranges between 10% and 50%

10. FUTURE OF GAP COVER National Health Insurance to replace gap cover?
Who will pay for the specialist costs?
Medical aids cannot afford it on current contributions
Specialists in short supply and high demand are unlikely to reduce fees
Members cannot afford it
NHI may extend PMB’s and then have a network of specialist who are prepared to perform these procedures at NHI rates but there will always be those Specialists who do not agree with this.
‘As long as the specialists continue operating in a free market and funding mechanisms are under strain, there will be a need for Gap Cover.’

11. GAP IS EASY TO SELL http://13.81.4.140:3838/Shortfall-tool/
Use the Shortfall indicator to show clients they cannot do without Gap Cover

12. EXAMPLE OF SHORTFALL INDICATOR
These are the potential shortfalls not covered by the Medical Scheme which will be covered by Zestlife subject to Policy terms and conditions.
Specialist Shortfalls
If you do not use a Specialist who has a payment arrangement with the Medical Scheme you could be liable for approximately 70% of the Specialist fees.
Co-payments
There is up to a maximum of R co-payment for the voluntary use of a non-DSP hospital which is covered subject to 1 claim per year and a maximum of R8 000
Prosthesis
If the cost of an internal prosthesis for spinal surgery exceeds R you will be liable for this extra cost
For PMB only - If the cost of an internal prosthesis for a hip and major joints exceeds
R or a knee exceeds R or other minor joints exceeds R you could be liable for this extra cost
R3 200 for all endoscopic investigations and specialised diagnostic imaging if in a private hospital

14. Thank
You