The Ombudsman for short-term insurance (OSTI) has warned customers of medical insurance to pay very careful attention when selecting medical care products – as the devil is the detail when it comes to accepting or rejecting claims.<\/p>\n
In the OTSI’s annual report for 2022, Junior Assistant Ombudsman Eunine Dlamini looked at a dispute regarding gap medical care.<\/p>\n
In the dispute, MR D registered a claim with his insurer for his wife’s hospital admission, where various medical treatments were performed on her.<\/p>\n
However, one medical procedure was rejected by the insurer as it was not covered by the medical aid scheme.<\/p>\n
Mr D said that he was entitled to the policy benefit as he was not made aware of the exclusions.<\/p>\n
The insurer said gap cover assists with \u201cshortfalls on authorised in-hospital procedures and a list of outpatient procedures where the providers charge over the medical aid scheme\/tariff rate\u201d.<\/p>\n
The medical scheme thus has to first pay a portion of each procedure code, with each amount charged according to the agreed scheme or tariff rate for the gap cover to start.<\/p>\n
The medical scheme did not make any contribution to the R8,750.68 charge as the scheme did not cover the benefit.<\/p>\n
The insurer rejected the claim based on the medical scheme’s policy exclusion.<\/p>\n
“The Insurer shall not be liable for any cost related to or in consequence of hospitalisation, bodily injury, sickness or disease directly or indirectly caused by: Any procedure or code not covered or declined or paid as an exception by the Medical Scheme unless specific cover has been provided in the Policy.\u201d<\/p>\n
The insurer said that Mr D was aware of the policy terms and conditions and was provided with a copy of the policy documents. It also provided proof of communication.<\/p>\n
The OSTI upheld the insurer’s rejection of the claims, as the benefit was not part of the scheme.<\/p>\n
It said that Mr D had the documents and was made aware of the policy terms and conditions.<\/p>\n
Dlamini said that policyholders should know that gap medical cover is a short-term\/non-life insurance product; it is not a medical scheme.<\/p>\n
Gap medical insurance covers the difference between medical aid scheme rates or tariff rates and the rates charged by healthcare partitioners.<\/p>\n
Like all other insurance products, it is subject to certain exclusions, exceptions, and conditions.<\/p>\n
Dlamini said that policyholders must acquaint themselves with their policy’s terms and conditions.<\/p>\n