2019 ZESTLIFE GAP COVER

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

2018 THE YEAR THAT WAS copy 1 copy 2 copy 3

BENEFIT ENHANCEMENTS AND PREMIUM INCREASE Universal option A few wording changes to clarify discrepancies Overall maximum increased from R150 000 to R160 000 Cancer lump sum increased from R25 000 to R30 000 Casualty benefit increased from R10 000 to R20 000. Casualty visit must be within 48 hours of the accident Premium waiver maximum R6 500 to R7 300 Dentistry maximum R15 750 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%

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.

BENEFIT ENHANCEMENTS AND PREMIUM INCREASE Essential option A few wording changes to clarify discrepancies Casualty benefit increased from R10 000 to R20 000. 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 R150 000 to R160 000

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 R25 000 per year Co-payment cover Casualty cover R20 000 Robotic machinery cover R30 000 NEW

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 R25 000 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 R30 000 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)

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%

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.’

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

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 R10 000 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 R26 500 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 R27 900 or a knee exceeds R34 400 or other minor joints exceeds R10 700 you could be liable for this extra cost R3 200 for all endoscopic investigations and specialised diagnostic imaging if in a private hospital

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