Master your medical aid

Master your medical aid

Renewing policies for the new year? Make sure your medical aid is right for your family – and that you’re making the most of it!

Your health, and preserving it, should be a top priority. As the saying goes, tomorrow is not guaranteed and you never know what lies ahead on your path. With cancer and heart disease on the rise in SA, sickness and accidents know no
age or social status. A recent study by the Institute of Race Relations (IRR) indicates that more than 44 million South Africans don’t have access to private medical care, making use of a heavily understaffed and neglected public health system that sees on average 4 219 people being treated per public doctor. It’s no wonder those who can afford to turn to medical aid schemes in order to access private healthcare and facilities.

‘Everyone needs some form of medical aid cover,’ says Michelle Morton, Fedhealth’s commercial executive.

‘Few of us could afford the costs of long hospital stays or care for serious injuries, surgery or chronic illnesses. Medical schemes help us finance life’s curve balls when we can’t do it alone.’ Medical aids, while expensive, are a safety net for you and your family, and with many options available, you can find one that suits your needs as well as your budget.

Hospital plan vs full cover vs medical insurance

Taking out full medical cover can come at a high cost, and for many South Africans it isn’t a realistic option. By law, both hospital plans and comprehensive options must cover a list of 270 medical conditions and 25 chronic conditions (prescribed minimum benefits) and their diagnosis, treatment and care. The main difference between them is that while a hospital plan and full cover will include all your medical expenses when you’re admitted to hospital and the duration of your stay, including the in-hospital expenses (consultations with doctors and specialists, operating or procedure costs, medication), full or comprehensive plans also cover general day-to-day medical expenses like
visits to the GP and dentist. ‘These comprehensive options have different amounts or limits available for day-to-day expenditure, and it’s important that you do a proper analysis of your day-to-day healthcare needs in order to select package that will cover the needs of your family,’ adds Michelle.

‘Some schemes also offer options that provide members with a safety net or threshold benefit, which means the scheme will continue to pay for day-to-day expenses once the normal day-to-day limits have been reached. There is, however, a self-payment gap during which the member has to self-fund before the safety net or threshold benefit is reached.’

A hospital cash plan, or medical insurance, works differently in that you’ll receive a cash amount for each day spent in hospital, and the amount is not dependent on the medical bills being incurred during the stay. It’s therefore not
associated with the prescribed minimum benefits list like the other two options, and is merely just a cash flow support during a time when it may be needed. The amount paid daily is dependent on the monthly payment towards the insurance policy.

‘Taking care of your family’s health is an investment in their future.’– Michelle Morton.

Ask the right questions

With so many options on the market it can be difficult finding the right plan that works for you and your family’s needs. Keep the following in mind when assessing current plans and providers or if on the market to join one:

Determine you and your family’s medical needs:

  • How often do you and your family members visit a GP?
  • Do you need to visit a specialist regularly?
  • Do you and your dependents have chronic conditions that require chronic medication?
  • How often do you attend other specialists, such as dentists or optometrists?
  • Will you be adding to your family? Some packages come with maternity benefits, as gynae consultations, antenatal classes and birth costs quickly add up.
  • If you own a savings account with your plan, did you exhaust your day-to-day benefits and/ or savings this year?

The plans on the market differ in price because of the benefits they offer. The more the plan costs, the more benefits you’re likely to receive, compared to cheaper options. Decide which benefits are relevant to you, and
whether they make allowances for situations outside your control, such as cancer or dialysis. Do their benefit programmes cover these conditions and treatments in full?

Before signing up, check on the company’s solvency ratio. ‘All medical schemes are required by law to have at least 25% of all contributions they receive in reserves,’ says Michelle. ‘It’s an important indication of a scheme’s financial health and is important to consider because it indicates how well the scheme is able to pay claims. You don’t want to be left in the lurch when your scheme cannot pay your claims.’

Find out what their medical rates are. These are essential to know, especially if you use healthcare providers who may charge more than the scheme’s claim rates, which most do. ‘The rates your scheme set every year for
each and every medical service, procedure and treatment are adjusted annually with inflation and are used as the basis of all tariff negotiations with healthcare service providers,’ says Michelle.


Check whether your employer is with a specific healthcare provider – perhaps they offer payment plans through the company.

Avoid exceeding your financial means by selecting a medical aid with contributions not exceeding 10% of your monthly income.

Tip: Some hospital plans have network restrictions, which means you can only make use of private hospitals on a specific network. These hospital plans are normally cheaper, but make sure you live in close proximity or have access to one of these private hospitals when you select a network hospital option.

Medical savings account

Many plans and schemes offer a medical savings account (MSA). This is a portion of your monthly contribution that you can use for day-to-day medical expenses, including visits to the GP, dentist, and other medical specialists
such as physiotherapists or optometrists. ‘The money placed in the savings account is your money and is not pooled with other members’ contributions,’ Michelle explains. ‘This provides you with a level of control over your spending.
Money in your savings account not used during a specific year will be carried over to the next year.’

Gap cover

Gap cover is designed to pay the ‘gap’ or shortfall between what your medical scheme pays, and what a private medical specialist charges. In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by five times. By taking out gap cover, you ensure that you and your family aren’t left with a large excess amount to settle.

Michelle’s top tips to make your medical aid work for you

  • Always use network doctors or specialists, as your scheme has negotiated special tariffs with them. This means you’ll be covered in full for these visits and not left out of pocket.
  • Pharmacies charge different dispensing fees, so always use network pharmacies where possible as medical schemes have negotiated the dispensing fee with these pharmacies.
  • If your scheme offers a free annual flu vaccination, make use of it to avoid getting sick during winter,
    which could easily eat up your savings account.
  • Choose generic medicines when you have your script filled at the pharmacy – in most cases they’re just as effective as the originator brands, and more affordable. This means fewer co-payments for you.
  • Designer eyewear frames can quickly deplete your savings account. Shop around for special deals on frames at major outlets. They might even do your eye test for free if you buy glasses from them.
  • Most medical aid providers have preventative care benefit systems in place. These platforms push you
    to make healthier choices, through exercise or purchasing healthy food, and reward you when you meet
    targets and reach certain goals.

Feature: Taryn Das Neves, photo:


Joni van der Merwe

About Joni van der Merwe

Your Family’s Digital editor. Avid retweeter. When I’m not scrolling Instagram you’ll find me in my garden. Keen on DIY and I don’t believe there’s anything that can’t be fixed with some chalk paint.


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