Medical Aid Application - Understanding the Application Process

Understanding the Medical Aid Application Process

While most of those who need to work for a living will, at some stage, also need to complete a medical aid application form in order to offset the cost of private healthcare, not everyone may be familiar with the requirements of the process or why much of the information requested is actually necessary. In practice, the process is not overly complex, but it will require the applicant to provide all of the information that may be asked for by a given scheme as a mandatory condition of entry.

To begin with, it is important to know whether or not it is the first time you are making a medical aid application. Those who have previously been members of another scheme will not be subject to the mandatory three-month waiting period that applies to first-time members. However, this exemption will only apply if you were still a member of that scheme at some time during the three-month period prior to your current request. If this was the case, it is only natural that you will also be required to attach documentary proof of your previous membership.

As for that waiting period, it is necessary to protect a scheme from those who might otherwise complete a medical aid application and then promptly submit an expensive claim only to cancel their membership as soon as their claim has been settled and they are no longer in need of attention. It is a precaution that also serves to protect other members from possible premium hikes.

Perhaps the most basic requirement is to provide one’s personal details and, as the form to be completed is a legal document equivalent to a signed affidavit, it is necessary to authenticate those details by including a copy of your South African ID document with a medical aid application.

Unlike the nation’s insurance companies, South Africa’s medical schemes are forbidden by their statutory body to discriminate against any potential member who might pose an increased risk. Insurers are entitled to respond, in such cases, by charging higher premiums and may even refuse to provide cover altogether. By contrast, while every applicant is required to provide details of any pre-existing condition as part of his or her medical aid application, a scheme is not entitled to increase its premiums or to refuse entry to anyone who admits to a pre-existing illness. Instead, the scheme is permitted to withhold cover for the declared condition for a discretionary period of up to 12 months, whilst honouring all of the member’s other claims.

On the upside, all schemes are now compelled to provide full cover for a list of 25 chronic illnesses with all of their products. The illnesses covered include asthma, diabetes, epilepsy, and hypertension, in addition to more than two hundred other prescribed minimum benefits (PMBs). For submission of claims associated with these, only a three-month waiting period is applicable while for those who are able to prove they have had continuous cover for more than 24-months, certain of these PMBs may even be made available within the statutory three-month waiting period.

Ensuring that a medical aid application is completed correctly is obviously important, but it is just as essential to choose the right scheme. A growing number of applicants believe this is KeyHealth.

Medical Aid - The Best Type of Medical Aid for Parents

The Best Type of Medical Aid for Parents

Given pressures on the state-funded healthcare services in South Africa, the only way to avoid long queues and even longer waiting lists, caused by staff and equipment shortages, is by switching to private healthcare. While both services are subject to high operating costs, private hospitals and practitioners recover these from patients, creating a need for the financial support of medical aid schemes. For parents, in particular, this tends to be extremely important, as children are frequently in need of specialist attention.

For such purposes, schemes offer a family membership in which the main member pays the bulk of the premium cost, while the cost of adding cover for a spouse or a child is substantially less. For a wife or partner who is already enrolled in a scheme at the time she becomes pregnant, the cost of the birth, the associated pre- and post-natal check-ups, and any subsequent paediatric care required by a new-born infant can be daunting, but will be covered by a good medical aid product intended for parents.

Once the confinement is over and mother and baby are safely back in their own home, more often than not, it will be the infant who is most frequently in need of some form of medical attention. It is, therefore, a comfort for the main member to know that the cost of visits to a paediatrician or an ear, nose, and throat specialist will be adequately covered when one is enrolled in a suitably comprehensive family scheme.

It is not all about the kids, though. Moms and dads also get sick, but need their health to look after them – another reason that the right medical aid is especially important for parents. While all of the schemes currently operating in South Africa will include a product in its portfolio that is able to offer the basic benefits referred to above, there is one that has chosen to go the extra mile and to focus on some of the needs of a family that other schemes have overlooked. Known as the Smart Baby Programme, it is the brainchild of KeyHealth.

This innovative benefit, included in all of the medical aid products is invaluable for prospective parents, and is provided at no extra cost. For the first-time mom, its maternity benefits include general advice on health and wellness during pregnancy, which can be a comfort for prospective dads too. Other benefits include a free copy of the “The New Baby and Childcare Handbook”, written by a well-known expert in the field, and access to a Facebook Group where new moms can exchange experiences and advice with others.

The Smart Baby Programme included as part of its medical aid services for parents also provides information on how to access other benefits, such as classes, ultrasound scans, vitamins, and vaccinations and, despite KeyHealth’s competitive premiums, this is not the only free benefit that is of value to members with babies and small children.

The Easy-ER facility was introduced as a medical aid service for parents, to provide their children with immediate access to a hospital emergency room in the event of a sudden illness or accident. KeyHealth has since extended that service to include the whole family.

Medical Aid - Affordable Medical Aid for Students

Creating More Affordable Medical Aid for Students

Meeting the cost of private healthcare can be a challenge even for those with a substantial income, and most South Africans are unable to do so without some form of insurance. To assist young adults who may be pursuing a course of full-time tertiary education who are covered by a family membership, it is often possible to extend their cover to apply beyond the age of 21. However, for those who may not have such an option, companies have found it necessary to introduce a more affordable type of medical aid product that is suitable for students.

For this purpose, schemes now offer the type of product known as a hospital plan. This should not be confused with the kind of cover provided by insurance companies under their so-called hospital cash plan policies. The latter simply pay a fixed sum of cash to the policyholder for each day that he or she is required to remain in hospital, and the accumulated total falls well short of the actual private healthcare costs incurred.

By contrast, the affordable medical aid product offered for students and other young adults have been designed to settle the majority, if not all, of their total bill. In both cases, cover only applies during those occasions on which a policyholder or scheme member is hospitalised during a given 12-month period. At all other times, the cost of GP visits and medication is for the account of the individual. Hence, premiums are lower than for more comprehensive products.

In this respect, the hospital plan is the perfect choice of affordable medical aid for students and others who, typically, are unmarried and enjoy sound general health, but who have insufficient income to meet the higher premium costs required for fully comprehensive cover. The occasional cough or cold can normally be overcome with one of the many cheap remedies available over the counter from a local pharmacy, but knowing that the cost of treating a major injury in the event of a motor vehicle accident or undergoing an emergency appendectomy will be covered is a great way for a young person to gain peace of mind.

The terms applied to affordable medical aid for students may vary between schemes, but one thing they all have in common is that they are obliged to cover the costs associated with the prescribed minimum benefits (PMB) mandated by the Council for Medical Schemes, even when these are not the reason for a member requiring to be hospitalised.

It is worth noting that insurance companies are under no obligation to cover PMBs in their cash plan products, and that some of the hospital plans proposed as an affordable medical aid option for students and young singles may offer benefits that others do not. For example, there are schemes that decline to cover the cost of medication issued at the time of discharge or of associated follow-ups as an out-patient while others are prepared to do so. It is, therefore, important to examine the terms and conditions of a product closely before committing oneself.

When searching for an affordable medical aid scheme in South Africa, many students now opt for the entry-level product offered by KeyHealth. It combines a comprehensive hospital pan with a number of valuable out-of-hospital benefits.

Medical Aid - How Medical Aid Scheme Rates are Determined

How Your Medical Aid Scheme Rates are Determined

In South Africa, only those who earn six- to seven-figure incomes can guarantee to meet the crippling cost involved in major surgery, unassisted, when undertaken at a private clinic. For the rest, some form of insurance to assist them with private healthcare costs is absolutely essential. Their solution is to enrol in a medical aid scheme with rates that are within their budget.

Unlike an insurance policy, these schemes do not simply offer their clients a fixed amount of cover in exchange for premium payments that are determined on the basis of perceived risks. This enables the insurer to set the cost of cover for each individual policyholder. By contrast, legislation introduced by the industry’s statutory body in 1998 forbids this form of discriminatory pricing on the part of a medical aid scheme which, therefore, means it is obliged to charge the same rates to all of its members, differing only in terms of the value of the cover they select.

For these specialised insurers, prices must be determined strictly on the basis of the estimated current cost of the treatments to be covered while remaining sufficiently affordable to attract enough members to create an adequate premium income. Without enough members, it might not be possible to retain a reserve of cash that is sufficient to meet all of its claims while still avoiding the need for a medical aid scheme to increase its rates. Given that these schemes are also not-for-profit companies, the need to exercise strict control over their operating costs is of paramount importance.

Despite their best efforts, there is little that can be done about the rising cost of private healthcare, and so, members can expect to face annual increases in their premiums. These, however, must first be approved by the statutory body, and every effort is made to keep them to a minimum.

A medical aid scheme must maintain affordable rates and adopts various methods to achieve this. While some reduce benefits and others attempt to boost membership with incentives, KeyHealth maintains value by appointing preferred service providers.

Medical Scheme - Understanding a Medical Scheme

Understanding How a Medical Scheme Works Can Avoid Problems

Most people probably tend to believe their private healthcare cover operates in much the same way as an insurance policy. However, although there are certain similarities, we really need to be grateful, because the two differ in some very important aspects. Though some members may complain about the cover they receive or the way in which their claims are processed, more often than not, their concerns occur as a result of their limited understanding of how a medical scheme actually works.

Yes, it is a form of insurance, but with a life policy or a hospital cash plan, the sums to be paid in the event of a claim are fixed and known in advance, giving the insurance company a clear idea of the ratio between its premium income and its potential liabilities arising from claims. This means that the total amount, which can be claimed by an insured party, can be based directly upon the cost of the premiums that they will be required to pay. When insuring a life, companies rely on actuarial tables to assess their risk, using that information to calculate individual premium rates.

By contrast, in understanding how a medical scheme works, the first thing to be aware of is that assessing an individual’s risk of illness or accident is impractical. Consequently, with regard to the premiums it charges for a given product, each member will pay precisely the same, for which each will receive exactly the same benefits.

Because the purpose of membership is not to compensate for a loss, but to cover the estimated costs of members’ private medical treatment as completely as possible, a scheme’s funds must be managed with exceptional care. Actually, the need for good governance is even greater given that, in South Africa, all such schemes must operate as non-profit entities.

The key to understanding a medical scheme lies in recognising that it must balance its potential risks and its operational costs with a sufficient surplus of cash derived solely from its monthly premium income. To do so requires the membership to be large enough while preserving a balance between its younger and generally healthy members and those of more advanced years who represent a correspondingly greater risk of more frequent and larger claims.

Apart from the uncertainties governing the same shared risk principle on which the insurance companies rely, there are some other factors that should improve one’s understanding of how a medical aid scheme differs from the products of the insurance industry. While the insurance companies have the right to refuse to provide cover for an applicant who is believed, based on past history, to pose a high risk, the specialised healthcare insurers are mandated to accept everyone regardless of their medical history. Instead, they may refuse claims for a pre-existing condition for up to a year, but are obliged to provide cover for over two hundred other conditions, including 25 chronic illnesses, such as asthma and diabetes.

Understanding how a medical aid scheme maintains affordable premiums is also important. Some simply limit their benefits to keep their costs down. Others rely on incentives to create the illusion of added value. KeyHealth, however, appoints preferred service providers to control costs without limiting benefits.