Medical Aid vs. Health Insurance

With the rising cost of living affecting every aspect of our daily lives, it is important to understand how you can better take care of your, and your family’s, health and healthcare expenses.

Medical Aid and Medical Insurance

Medical Aid vs. Medical Insurance
Very few South Africans are fortunate enough to be in a financial position where they are able to take care of all their medical expenses – whether planned or unexpected. Our government healthcare system is notoriously poor and unreliable and unfortunately cannot be counted on. This leaves us in a position of needing to ensure that any possible healthcare costs are covered.
In S.A. we generally have 2 ways of approaching this, Medical Aid or Medical Insurance. We’ve put together this guide to help you choose which is most suitable for you and your needs.

medical Aid

How It Works

A Medical Aid scheme is required by law to be registered with the Registrar of Medical Schemes. For a set monthly premium a member and their dependents (if included) will gain from a set of standardised minimum medical cover benefits based on the medical scheme tariff which is determined by the member’s selected plan.

This means that depending on the plan, there may be limitations on which service providers and facilities the member may have access to. As most know, the better the plan, the more comprehensive the range of cover is available. This includes hospital cover and in-hospital treatments.

Medical aids also legally have to cover a list of Prescribed Minimum Risk benefits that include a vast array of life-threatening emergencies as well as up to 26 Chronic Medical Conditions. Medical Aid schemes generally have a minimum waiting period of 3 months before full cover is available but be advised this can also include claim exclusions for up to 12 months for pre-existing conditions.

Your medical Aid scheme will generally settle your medical expenses directly with your doctor or service provider (ie: hospital, radiologist, pathology lab etc.), up to the medical scheme tariff amount covered by your plan. This is unless the doctor or provider is not accredited or recognised by your scheme, in which case they will pay you out once you have settled the account yourself and submitted the invoice to claim.
Depending on your plan and how much your service provider charges, this may leave you with a shortfall that you may have to settle out of your own pocket. This is where Gap Cover comes in (view our options available[link to Gap Cover page]).

It is recommended that if you or a family member struggle with a serious medical condition that requires frequent hospitalisation or specialist treatment, or if you’re planning on starting a family within the next year or 2, then a comprehensive medical aid is probably more suited to your needs.

Chat with us about your Medical Aid options now.

Medical Insurance

How It Works
Medical Insurance is a relatively new concept in South Africa and caters more to a client base who either can’t afford a medical aid or who are generally healthier and have no real need for one. Medical or Health Insurance products do not fall under the same regulations as Medical Aid schemes and are instead governed by short-term or long-term insurance law. Medical Insurance plans are far more flexible and generally more cost effective than Medical Aid products.

A client’s chosen plan is designed to cater to their specific healthcare needs using the plan’s individual scope of benefit limitations up to a specific monetary value.

Like most insurance policies, Medical Insurance premiums can differ from individual to individual depending on various factors including member’s age, family size, medical history and pre-existing conditions. Although Medical Insurance plans do cover emergency hospitalisation and necessary procedures they generally provide less in-hospital cover than Medical Aid plans and may require that you use the plan’s network of approved medical providers. It is also worth noting that should you be scheduled for a planned surgical procedure you may need to provide a guarantee of payment letter before being admitted.

Waiting periods for cover of Health Insurance products vary depending on the particular product/s the member wants cover for. We strongly advise you to do your own research and to discuss this with your broker first so that you fully understand the limitations on your plan and to be sure that this will work for you.
With Health Insurance products, you are personally responsible for all your medical bills which you will then claim back from your Medical Insurance up to the limits set in your chosen plan. Medical Insurance products are mostly focused on out-of-hospital primary healthcare – such as GP visits, prescribed medications, basic dentistry and some optometry cover – and is as such better suited for day-to-day medical expenses and accident & emergency cover.

Did you know?
Health insurance policies can also include death and funeral cover.

Summary

Medical Aid vs. Health Insurance Health Insurance
Medical Aid
  • Set premium for standardised minimum medical cover as defined per chosen plan.
  • Includes Prescribed Minimum Risk benefits by law.
  • Numerous plan options available but may limit cover and/or access to services depending on plan.
  • Best option if you or a family member struggles with a serious medical condition.
  • Does not include any form of disability, death or funeral cover.
  • Legally required to be registered with the Registrar of Medical Schemes.
  • Generally a 3 month waiting period before full cover.
  • Can include a 12 month claims’ exclusion for pre-existing conditions.
  • Obligated by law to charge members the same premium for the same plan.
  • Medical Aid schemes are more expensive but generally have more comprehensive cover.
  • You may be liable for any shortfall between Medical Aid rates and what service providers charge (Gap cover products are available to help with this).
  • Provide full cover for a list of treatments and/or conditions as per the plan’s limits.
  • Prescribed MInimum Risk benefit cover which includes 250+ in-hospital, life-threatening and 26 listed chronic conditions.
  • Legally obliged to cover chronic medication if you meet the necessary requirements.
  • Comprehensive hospital cover with a large variety of in-hospital treatment depending on your plan.
Health Insurance
  • Chose from a list of selected benefits with a monetary value attached to each.
  • Customisable cover serviced through a network of approved providers.
  • Suitable for simple healthcare needs with day-to-day medical and limited hospital expenses covered.
  • Cover is generally set as a rand value per day or overall monetary limit per year.
  • Policies can include death & funeral cover.
  • Legally regulated under short-term or long-term insurance law.
  • Dependent on the particular product/s selected.
  • Each product can apply a different waiting period.
  • Premium depends on cover selected.
  • Premium is also determined by various factors including person’s age, family size and pre-existing conditions.
  • Although more affordable there are limitations to cover provided.
  • Generally focus on day-to-day healthcare cover such as GP visits and short-term medication.
  • A more comprehensive plan will include hospital cover up to a fixed amount but is generally limited to accident & emergency cover.
  • Only specified hospital costs are generally covered with members being personally liable for any extras.
  • Planned surgical procedures generally require a letter guaranteeing payment before admission.
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