1. 2020
ZESTLIFE GAP COVER

2. 2019 THE YEAR TO DATE
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 as of 31/08/2019 = R
Average claim amount R7 760
Average claims received each month 1078
75% of claims are paid 25% repudiated

3. MEDICAL AID What is Medical Aid? Prescribed Minimum Benefits
They are the main funders of private Healthcare in SA
Premiums paid are pooled and used to pay Health Care expenses in accordance with Scheme’s rules and the plan option
Prescribed Minimum Benefits
A set of minimum Healthcare benefits that must be paid in full
Schemes use tools like networks, Designated Service Providers and formularies to manage costs
25 Chronic conditions and 270 Medical conditions (diagnosis and treatment pairs)

4. 100% MST 200% MST MMB Hospital Plans
MEDICAL AID PLANS
MAJOR MEDICAL BENEFITS
In-hospital procedures
Day procedures
Co-Payments
Oncology
Dialysis
Internal Prosthesis
Chronic Conditions, etc
100% MST
200% MST
MMB
Hospital Plans

5. MEDICAL AID PLANS – 100% VS 200%
Tariff for Gynae costs, for Natural Childbirth is R3 650
Gynae charges R13 500
@ 100% (1 x tariff) Gynae is paid R3650,
client liable for a shortfall of R9 850
@ 200% (2 x tariff) Gynae is paid R7 300,
client liable for shortfall of R6 200

6. WHY YOU SHOULD SELL GAP COVER
All medical aid members need it
It is a great door opener
Gap Cover is quick and easy to sell
You can earn good annuity income with ease

7. CLAIMS PAID FOR 2019
Examples of medical procedures that are frequently not covered in full by medical schemes
Examples of medical expense shortfalls paid by Zestlife Gap Cover in 2019
Natural Childbirth
R22 910
Caesarean Section Childbirth
R26 379
Tonsillectomy
R  6 891
Hernia Repair
R42 803
Breast Cancer Surgery
R87 221
Knee Replacement Surgery
R69 127
Hip Replacement Surgery
R77 316
Spinal Surgery R
Cancer Treatment R
Heart Surgery R

8. 2020 BENEFIT ENHANCEMENTS
Essential and Universal Gap Cover policy options
Overall medical expense shortfall and co-payment cover limit per individual insured under the policy will increase from R to R per annum.
Vasectomy and female surgical and non-surgical permanent sterilization will now be covered. This cover applies to both in-hospital and out-of-hospital procedures.
Day Clinics Cover, treatments received in day clinics will now be covered.
Medical expense shortfalls arising from an accident or illness while travelling outside of the borders of South Africa for a period of less than 60 days will be covered. (Not including cancer treatment and other planned procedures outside of South Africa).

9. 2020 BENEFIT ENHANCEMENTS
Additional limit increases for Universal Gap Cover option:
Non-network Hospital Usage Limit will increase from R9 300 to R
Internal Prothesis and Artificial Joint Cover will increase from R30 000 to R35 000.
Medical Aid and Gap Policy – Premium Waiver Cover will now be payable as a lump sum benefit equal to 12 times the combined premiums as at claim incident date, up to a maximum of R

10. 2020 BENEFIT ENHANCEMENTS
Additional benefit for Essential Gap Cover option:
Accidental dental benefit which provides cover up to a maximum of R2 750 for each tooth, for an accidental tooth fracture due to an external blow to the mouth where the likely treatment is a crown, splinting or a bridge. Deciduous teeth are excluded. This benefit is limited to R19 250 per year for each insured person.
Extended Cancer Cover Increase
The two cover amounts for this optional lump sum benefit will increase from R to R and from R to R

11. 2020 ESSENTIAL GAP CALCULATION CHANGE
Medical expense shortfalls that are covered by the Essential Gap Cover Option will be calculated differently.
Current Definition
New Definition – 2020
Medical Expense Shortfalls are calculated as:
The (combined doctors and specialists charges, up to but not exceeding 3 times the medical schemes contribution towards these charges) less the (greater of either the medical scheme’s payment towards these charges or the medical scheme’s tariff amount [MST] payment towards these charges).
Medical Expense Shortfalls are calculated as:
The (combined doctors and specialists charges, limited to 3 times the medical scheme’s tariff amount [MST]) less the (greater of either the medical payment towards these charges or MST).

12. ZESTLIFE ESSENTIAL GAP COVER
MEDICAL
EXPENSE
SHORTFALL
HEALTH
INSURANCE
BENEFITS
Limited to 3 TIMES TARIFF
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
Accidental Dentistry R19 250
NEW
Casualty cover
R20 000
Robotic machinery cover
R30 000

13. HEALTH INSURANCE BENEFITS
ZESTLIFE UNIVERSAL GAP COVER
MEDICAL
EXPENSE SHORTFALL
HEALTH INSURANCE BENEFITS
Limited to 3 TIMES TARIFF
Non DSP co- payments up to
R 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
Up to R cover for internal prosthesis
R cancer lump sum on first diagnosis
Robotic machinery cover
R30 000
In-hospital dentistry shortfall
20% of ongoing cancer costs after medical aid limit
is reached
Premium waiver on accidental death and disability.
R limit
(age 65)

14. All commission is 20% except Universal older than 65 which is 15%
PREMIUMS 2020
Zestlife Universal Gap
Zestlife Essential Gap
Cover for Individuals
2020
Younger than 55 years old
R401
R296
55 – 64 years old
R506
R372
65 years old
R568
R424
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%

15. EARN ANNUITY INCOME Use the Commission Calculator
10 Gap Policies = R800 per month
30 Gap Policies = R2400 per month
100 Gap Policies = R8000 per month
500 Gap Policies = R per month
1500 Gap Policies = R per month
Very low lapse rate.
Commission grows annually with each premium increase higher than inflation.

16. GAP BROKERS Broker Commission Paid Jan 2018 Number of policies 2558
912 policies which includes 9 cancellations
0735 R
512 policies which includes 11 cancellations
0250 R
392 policies which includes 5 cancellations
0123 R
360 policies which includes 10 cancellations
2086 R
299 policies which includes 10 cancellations

17. 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.’

18. GAP IS EASY TO SELL
Use the Shortfall indicator to show clients they cannot do without Gap Cover

19. 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 R 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

20. ZESTLIFE GAP COVER ONLINE APPLCIATION

21. SOME INTERESTING STATS ON LAPSES
Reason why client cancelled
2016
2017
2018
LAPSED DUE TO NON PAYMENT
25.06%
19.46%
15.46%
AFFORDABILITY
10.63%
14.06%
15.66%
NO LONGER REQUIRES COVER
11.38%
11.90%
16.67%
CANCELLED MEDICAL AID
11.43%
9.10%
8.32%
NO REASON PROVIDED
5.96%
11.33%
9.89%
NOT SATISFIED WITH THE POLICY
4.95%
5.70%
6.19%
CANCELLED AFTER PREMIUM INCREASE
9.00%
4.16%
0.86%
HAS SUFFICIENT COVER
3.69%
5.54%
4.67%
DECEASED
4.24%
3.86%
CHEAPER POLICY
2.45%
4.01%
5.56%
RETENTION UNABLE TO REACH CLIENT
2.34%
3.60%
2.59%
From the year

22. Thank
You