PSG Konsult Corporate (PSGK Corporate) recently facilitated a discussion around decision making in the health care industry. This addressed both the draft demarcation regulations and the potential impact of these on the future of health insurance products such as gap cover.
Participants included Tiago De Carvalho, the Managing Director of Ambledown Risk and Underwriting Managers, who specialise in the area of health insurance underwriting and John Cranke, the head of health care at PSG Konsult Corporate. Cranke was responsible for drafting PSG Konsult Corporate’s response to the draft demarcation regulations.
Anton Le Roux, Head of Business Development at PSGK Corporate who facilitated the discussion says, “Decisions about health care provisions for employees can be daunting at the best of times – and doing so in a fast changing legislative environment can seem impossible. Despite there being no central repository of information in respect of health insurance products, we estimate that approximately 300 000 families currently have active gap cover policies in South Africa.”
What are the practical implications of the proposed changes to Demarcation Regulations?
According to De Carvalho, the draft regulations propose to introduce different categories of accident and health insurance policiesincluding:
- Lump sum or income replacement policy benefits payable on a health event
- Motor and property third party liability
- HIV and Aids
- International and domestic travel insurance
- Emergency evacuation and transport.
The proposal is to outlaw gap cover in the future
De Carvalho says the effect of the proposed changes is that policies which fall outside the scope of the regulations, such as gap cover policies, will be outlawed in the future. In addition to this, exempted policies, which were entered into by an insurer after 15th December 2008 must be brought in line with the Regulations. “It is important to remember that these Regulations are only in draft stage. They were introduced on the 2nd of March this year and were open for comment until 23rd April 2012. There was an overwhelming response from both the industry and public and the Department of Treasury is currently working through the submissions and we await their response.
“It is not the first attempt by the Council for Medical Schemes to abolish health insurance products. A few years ago they targeted Guardrisk, by issuing an interdict against them to prohibit the marketing of gap insurance products. After a two year legal battle, the Supreme Court of Appeal found that gap cover products were lawful and in line with both the and .
The Court acknowledged that the definition of a medical scheme had been drafted deliberately to take into account the definition of ‘Accident and Health Policy’ in the Short Term Insurance Act and to allow both definitions to co-exist amicably. Over and above this, the judge stated that practically there was a need for this type of insurance.
However, now regulators are trying to change the definition of a medical scheme in order to get around the issue.”
Turning the screws…
Following the publication of the draft regulations, the Minister of Finance, Pravin Gordhan, stated that the draft regulations seek to address the risk of possible harm caused by health insurance products drawing younger and healthier members away from medical aid schemes. However, many have vehemently denied this. De Carvalho and Cranke agree that the lines mustn’t be blurred between medical aid schemes and gap cover.
Gap cover is a complementary medical scheme product and it is a condition of cover that a person is also a medical scheme member. Other health insurance products, such as hospital cash plans are intended for those who cannot afford medical scheme cover. This is important as only 15% of South Africans belong to a medical aid scheme, the remainder seek other products.
The argument that that the draft regulations serve to strengthen and preserve the social solidarity principle that underpins medical schemes is also countered by De Carvalho and Cranke.
They say that gap products are not priced on traditional pure insurance principals at individual level – but across a risk pool at either employer or product specific level (although it is accepted that in some cases there is premium differentiation based on age). It can therefore be argued that gap products also uphold the social solidarity principles of cross subsidisation.
Do members opt for a cheaper medical scheme when they buy gap cover?
The argument that members buy-down to a cheaper medical scheme option once they have a gap cover policy in place does not sit well with Cranke. He says, “In our experience very few medical scheme members select cover based purely on need and, rightly or wrongly, often the most important consideration is affordability. Medical Schemes offer an annual opportunity to upgrade and most gap products are only considered after the option choice has already been made. The reason for this is that across all medical schemes there are very few (if any) options that can guarantee members no shortfalls in respect of in-hospital cover.”
Cranke backs this up with stats from a recent review of 11 medical schemes conducted by PSGK Corporate. These represent approximately 90% of the open medical scheme market in terms of membership and it indicated that only 36% of the options in the 11 schemes reviewed provided cover in excess of the base medical scheme reimbursement tariff and that four of the schemes do not provide any cover in excess of the base medical scheme reimbursement tariff.
Does this mean that members on one of these schemes are not able to buy-up to obtain more cover even if they could afford it?
Members will almost definitely be faced with shortfalls says Cranke. Depending on their reason for being admitted to hospital, the shortfalls in respect of the service providers can run into several thousand rands. So we are back at the affordability issue.
Why are there buy downs then?
It makes more sense that buy-downs are driven by the consistently higher than inflation increases declared by the medical schemes. This is particularly relevant for pensioner members, who increasingly have no post-retirement medical aid subsidy to rely on, and struggle to keep up with a variety ofdemands (e.g. escalating electricity and transport costs) on incomes that are tied into very low interest rates.
Neither Cranke nor De Carvalho believe that health insurance cover impacts negatively on medical schemes. Carvalho says,
There have not been any studies or surveys undertaken to investigate the impact of gap cover products on medical schemes and it is actually one of the recommendations that we made in our submission to Treasury. It is difficult to find a qualitative or quantitative measurement. The health insurance industry would welcome a study of this nature.
Cranke says that without a study, it would be difficult to make anyconclusive findings as to the impact of gap cover products on medical schemes. Added to this is the fact that medical schemes themselves have taken opposing views. "Not all schemes are opposed to gap cover; there are in fact schemes that support gap cover products to the extent that they have their own products in place!”
Does the draft demarcation regulations infringe on consumers’ constitutional rights?
De Carvalho says that, “In terms of Section 33 of the Constitution we (the public) are given the constitutional right to just administrative action, which imparts the right to challenge administrative action and in so doing it compels us, as a society, to ensure that government is democratic, accountable, open and transparent.
Unjustly denying the policyholder of gap cover is infringing on the individual’s right to choice. Particularly, because no evidence exists or was provided by the regulators showing that gap cover policies compromise the key principles of social welfare, solidarity and cross-subsidisation found in medical schemes. In this instance, administrative decision adversely affects the rights of South Africans by denying consumers their democratic right to provide properly for an unforeseen event that may lead to financial difficulty. There is potentially a case to be made.”
So where does South Africa stand in respect of draft regulations?
De Carvalho says, “We are waiting for a response, in the form of a second round of Draft Demarcations – hopefully before year end. As it stands now gap products are legal. The response from both industry stake holders, as well as members of the public was overwhelming and the Treasury are considering all submissions. They met with stakeholders, such as the South African Insurance Institute and underwriting managers, such as ourselves, in August, but they were carefulnot to divulge too much. One must also remember that the effective implementation of the draft demarcation regulations, in their current form, requires that the definition of a medical scheme, as outlined in the Medical Schemes Act, be amended. This is being done via the General Law’s Amendment bill which was tabled in parliament recently.”
So what should employers who offer employees gap cover and hospital cash plans do?
Cranke says, “It certainly is not an ideal situation, but we are recommending that employers and members alike sit tight for the time being. Despite the current discussions, gap cover still has legal standing. We believe gap cover has a place, given the current uncertainty regarding tariff negotiations between providers and medical schemes, gap is more relevant than ever. As long as the products remain legal, keep your cover in place.”
De Carvalho adds that he remains positive that the regulators, after considering submissions, will realise that there exists a real need for these types of products and that removing them will place policy holders at risk. “At the very least, policy holders will have cover until 31 December 2012, after which the policy will either be renewed in its current form, cancelled or amended as required by the regulations. We however remain hopeful that sanity will prevail.”