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Understanding Medical Aid Terminology

Many South Africans are unaware and unconcerned about the terminology used in the medical scheme industry. Quite honestly, when searching for medical aid cover, South African families are only concerned with the benefits they receive and keeping the price of the plans at an affordable rate. Yet understanding the various terminologies used in the industry are equally as important because when you are faced with an illness or a medical problem and you need to claim for it from the medical aid, you don’t want to learn that the thing you didn’t understand when signing up to the plan is what you have been excluded from.

This is why it is necessary to familiarise yourself with the different industry jargon so as to be better prepared for anything that might come your way. It will also allow for a better understanding of what coverage you receive, and what limitations there are. It will allow you to make fully informed decisions about the type of coverage you receive for your family, and what value you’re getting for your money.

Here are a few terms and jargon often used in the medical scheme cover industry.

Medical Scheme Cover Jargon – Day-to-day Benefits

The day-to-day benefits that is frequently referred to in the industry is the combined out of hospital benefit that you receive from your medical aid scheme. These benefits can range from optical services, radiology, GP visits, pathologist services, specialists and medical services that are rendered outside of a hospital. It will also include prescribed medicine and any such related services and specified self-medication.

This is an important aspect to take into account when searching for medical scheme cover and you should be comfortable with the amount of day-to-day benefits that you receive.

Chronic Disease List

This list refers to chronic diseases that forms part of the Prescribed Minimum Benefits of which any South African medical aid is required to cover in state hospitals. The public can view this list at the Council for Medical Schemes. It lists roughly 25 chronic diseases, and also 270 emergency conditions. The conditions are stipulated under the Medical Schemes Act of No. 31 of 1998.

Designated Service Provided

A Designated Service Provider is an approved service provider by the medical aid which renders its services to the scheme’s members according to an agreed upon tariff structure. In this instance the Designated Service Provider will also be the only service provider which is covered by the medical aid. Should a service provider offer cheap medical hospitalisation rates, but isn’t one of the Designated Service Providers of the scheme, its fees won’t be covered as part of the benefits ascribed to the scheme’s members.


According to the Medical Schemes Act of 1998 there are various stipulations that that dictates the cover that medical aids need to afford for treatments, including emergency care. A medical emergency which requires immediate hospitalisation, medical care or surgery without which the member could suffer long term health issues or death needs to be dealt with immediately.

These are only a few of the industry terms that you need to be familiar with.

KeyHealth Medical Scheme Cover

At KeyHealth Medical we work hard to provide our current and prospective members with all the information they will need to make informed decisions regarding their family’s health cover. Our committed staff is at hand to help you learn about all the various benefits you receive from your medical scheme cover with us and the many other advantages to taking out cover through us.

We have been operating successfully in the South African medical aid industry for many years because of our dedication and commitment to providing value for money for our members. Our value-adding services and products go a long way in ensuring the health and well-being of our members. With more than 90,000 members and growing, this all attests to the satisfaction of our members and our competitively priced packages.

We have a medical scheme cover for every South African family, regardless of your budget. You can now sleep sound at night knowing your entire family is well-looked after. Contact us for affordable medical scheme cover in South Africa.