Choosing the right medical aid

Last updated on 13th December, 2017 at 10:20 am

It doesn’t matter how young, fit and healthy you are ­– all of us become ill at some point in our lives for which we need a medical cover. But with an array of options, which one is right for you? We investigate.

A medical aid not only provides cover for costly medical procedures at private facilities, it also guards you against emergency medical expenses that are very often too high for the average person to pay out of his or her own pocket. Your health, age and marital status determine which type of medical aid is right for you. Fortunately all medical aids in South Africa are nowadays required to pay for certain prescribed minimum benefits (PMBs), such as:

• any emergency medical condition (anything sudden and unexpected that requires immediate medical treatment and/or an operation)
• a limited set of 270 medical conditions (including certain types of cancer, heart attacks, hip fractures, HIV/AIDS and TB)
• 25 chronic conditions (including diabetes, asthma, certain heart conditions and epilepsy)

[Go to the Council for Medical Schemes website for a full list of benefits.] Let’s look at what medical cover is appropriate at what stage in your life:

Starting out or newly married

A hospital plan is ideal for young people who have just started working, or a newly wedded couple, as it is more affordable than plans with comprehensive cover. You have direct control over your medical expenses, plus you have core medical cover in case of emergencies. It’s a good idea though to have a separate medical savings account for dentistry, doctors’ visits and acute medication for minor illnesses, such as colds and flu. Hospital plans generally cover:

• Hospital expenses, but the specific plan may compel you to only use designated facilities.
• 25 chronic conditions (as stipulated in the prescribed minimum benefits).
• Some procedures, such as gastroscopies, colonoscopies in doctors’ rooms.
• Unlimited MRI and CT scans in and out of hospital.
• A limited number of maternity consultations.

Young families

A medical aid with day-to-day benefits that provides you with cover for serious conditions and hefty expenses, such as hospital procedures, but also day-to-day benefits is a good choice for young families. This benefit should provide cover for:

• Private hospitals in South Africa, paid at 100% of agreed tariff for elective hospitalisation.
• GP visits, specialist visits and acute medication.
• Basic dentistry, pathology, radiology and physiotherapy.
• Optometry.
• Certain clinical procedures (gastroscopy, colonoscopy, tonsillectomy).
• MRI and CT scans in and out of hospital.

Older families

A medical aid with comprehensive cover is the optimal option for a more mature family, with or without dependants, who want to have peace of mind for any eventuality, but who are willing to make small co-payments on certain procedures. This benefit should provide for:

• Unlimited hospital cover for any PMBs at a private hospital in South Africa, paid at 100% of agreed tariff.
• Specialist visits, usually covered at 80% of cost in and out of hospital.
• Joint replacements.
• Oncology benefits, cover for biological drugs.
• More comprehensive cover for chronic conditions.
• Optometry.

Gap cover

For an affordable amount per month, medical gap cover pays the difference between what your medical aid settles and the rates charged by medical specialists, which are often higher than what medical aids pay. In some instances in-hospital procedures or outpatient treatment may be five times higher than the base medical aid rate, which can leave you in a financial pickle. But if you have medical gap cover insurance, you and your family won’t be left with a large excess amount to settle.

By Liesl Peyper