Ina Opperman

By Ina Opperman

Business Journalist

Looking for a medical aid scheme? Here’s how to choose the best one for your needs

You have to follow the right steps to choose a medical aid scheme that will benefit you and your family and cover your expenses.

What do you look for when choosing a medical aid scheme? This is a question many consumers struggle with.

It is expensive to be a member of a medical aid scheme and therefore a grudge purchase that consumers do not like to pay, especially if they and their families never get sick.

They only realise the value when someone does get sick, like many did during the pandemic, or when a family member is injured in an accident. Choosing a medical aid scheme is not something you do off-hand and you have to approach this important decision carefully.

You have to ensure that you can afford the membership and that you get the cover you require, which is why you should keep the following tips in mind.

Check your budget

It can be a costly exercise and therefore you have to look at your budget to see how much you can afford per month.

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What do you require from your medical aid scheme?

To determine what you require from your medical aid scheme, the answers to these questions will help: Are you single or do you have a family that needs medical cover? How old are you and your spouse?

Do you have children and what are their ages?

Are there any hereditary diseases in your families?

Do any of you suffer from a chronic disease that requires continuous treatment or is your family healthy and follow a healthy lifestyle?

Does your child get sick every winter?

Ask people you know about their medical cover

Ask family and friends and your general practitioner if they are happy with their medical aid schemes.

Ask if their claims are paid promptly or do they have to spend days on the phone to sort out an unpaid doctor’s account?

A good medical aid scheme pays on time and has good guidelines that make it clear what it pays for.

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Ask an expert

Once you have decided to join a medical aid scheme, make an appointment with a broker for medical aid schemes, as it is important to chat to someone who does not want to sell you membership to one specific scheme, who can help you choose the right one for your needs.

Check the medical aid schemes reserves

Medical aid schemes must, according to law, have at least 25% of its members’ contributions in reserve and must invest it to ensure that funds are available to pay out claims.

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What does the medical aid scheme offer?

You have to be careful of medical aid schemes that make huge promises with many benefits, but when it comes to paying out claims, offer very little with many exclusions.  

Consider the day-to-day limits and how much your medical savings account will be per year. For example, if you have a child who often gets sick, your benefits could be depleted by April if the savings account only provides a small amount.

Also look at how much you will have to pay from your own pocket, compared to what the scheme will cover.

Consider the size of the hospital benefit and see if you will be limited to specific hospitals and if so, if one of these hospitals is close to you. It is ideal to choose a fund that provides 200% of the fund rate for hospital treatment.

If you have to get medical cover for a family of four, a medical aid scheme that pays out R600,000 per family per year will not be worth much, as many families saw during Covid when whole families had to be admitted to hospital.

Cancer treatment is also an important factor. How is the cancer treatment determined and will the medical aid scheme pay for new treatment if someone in your family develops cancer?

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Medical aid schemes usually have two exclusions: exclusions for less than a year when you are a new member and exclusions that will last forever.

You should first check these exclusions and ensure that you are satisfied with them before joining a medical aid scheme.

Would a hospital plan not be better suited?

Although hospital plans are often more affordable than membership of a medical aid scheme, you have to remember that a hospital plan only pays out when you are admitted to hospital, depending on certain conditions.

A hospital plan only pays out to provide for loss of income and not for direct medical expenses.

Direct medical expenses can be much more than the amount the hospital plan pays.

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Medical aid scheme or medical insurance?

Your medical aid scheme pays for medical conditions up to scheme tariffs, but health insurance, like all insurance products, will pay out a fixed amount if something specific happens to you, instead of paying out specific amounts for specific medical services.

Medical insurance provides for loss of income and contingency expenses but not direct medical expenses. The medical expenses may also exceed these contingency expenses by far.

Medical aid schemes and medical insurance providers are controlled and governed by legislation and statutory regulation bodies.

According to the Medical Schemes Act, certain medical conditions and emergencies, called Prescribed Minimum Benefits (PMBs), must be covered in full by the medical schemes regardless of the plan type you are on, but medical insurance does not have this requirement.

 There are more than 300 PMBs that include emergencies, most cancers and 27 chronic conditions such as asthma and diabetes. The benefits of medical insurance are not guaranteed by law.

Medical aid schemes also offer open enrolment and community rating. Anybody can join a scheme of their choice and may not be turned away, and all members pay the same monthly contribution for the same benefits within the scheme plan option.

With medical insurance on the other hand, your premiums are determined by the state of your health. If you have a pre-existing health condition, you will pay more for medical insurance cover and you can even be refused cover if you are too much of a risk.

Medical schemes operate in a similar way as a mutual organisation for the benefit of members and not for profit, governed by a board of trustees. Medical insurance is provided by long-term insurers owned by shareholders expecting a profit.

Consumer protection

Medical insurance is regarded as long-term insurance and is therefore regulated by the Long-Term Insurance Act enforced by the Financial Services Board.

Medical aid is governed by the Medical Schemes Act which is enforced by the Council for Medical Schemes. This means that your consumer rights regarding medical aid and medical insurance are different.

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