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Providing Cover for All with a Family Medical Aid Plan


Given that more than 90% of those who receive healthcare from the country’s private sector is only able to enjoy this facility due to the cover provided by specialist insurers, today’s South African family has become almost totally dependent upon the support of the nation’s medical aid plans. While they also offer appropriate products for the individual, most of these not-for-profit companies operate schemes designed to cover the private healthcare needs of a principal member, his or her spouse, and a maximum of three dependent children.

In a typical year, most families can expect that one or two of its members might suffer a cold or a bout of flu that will require an appointment or two with their GP, while young kids tend to suffer various minor injuries that can normally be remedied with some over-the-counter product from the local pharmacy. If these were the only health issues to be faced, healthcare costs would be minimal, and there would be little need for a family to consider investing in medical aid plans. Unfortunately, life is seldom that simple, and in any group of individuals, the risk of a more serious illness or an accident is a contingency against which a responsible spouse or parent will naturally want to arrange suitably comprehensive insurance cover.

Often, it is the children who are prone to require the most attention, especially during the early years of their lives. At this time, the rather more costly services of a paediatrician or an ENT specialist are more likely to be called upon than those of a general practitioner. As they get older, the next problem area will typically be their dental health and, if this should happen to include a protracted course of orthodontic treatment, it could put a serious dent in the family budget if not enrolled in one of the more comprehensive medical aid plans available to the citizens of South Africa.

One form of cover that applies to all products apart from the so-called hospital plan whose benefits apply only when a member or dependent is hospitalised is year-round funding of the prescribed minimum benefits (PMBs) introduced by the Council for Medical Schemes (CMS) in 1998. These form a mandatory component of all other products and, for example, provide cover for all costs relating to the diagnosis, treatment, and care of approximately 270 conditions, including twenty-six named chronic illnesses. The latter includes conditions, such as asthma, epilepsy, diabetes, and hypertension.

While all family medical aid plans are obliged to provide cover for PMBs, they are also entitled to apply exclusions. These are generally applicable to cosmetic surgery, examinations for insurance purposes, and travel costs incurred during treatment. However, all new members are subject to a mandatory waiting period of three months before they are permitted to submit claims. Furthermore, nobody may be refused membership of a scheme because they have a pre-existing condition. Instead, new members who are in this position will generally be required to wait 12 months before any claims relating to that specific condition will be met.

Clearly, if they are to be effective, family medical aid plans need to be both affordable and provide all of the necessary cover – both sound reasons for applying to KeyHealth.