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The Nature and Importance of Medical Scheme Cover


Since the earliest days of the state health service in South Africa, pressures on its resources have been mounting and, just a few years after it was launched, the need for a parallel private service was already becoming apparent. Today, that need has never been greater. Like any other business, however, private hospitals, clinics, and practices all need to make profits to survive and the costs of medication, equipment, accommodation, and salaries are considerable. The reality is that, without adequate medical scheme cover, most South Africans would be unable to afford private healthcare.

Unlike these private facilities, the bodies responsible for providing this type of financial assistance are all non-profit organisations, and are governed by a board of trustees. In addition, they must be registered with the CMS, an official body appointed by the state that acts as their regulator. Known in full as the Council for Medical Schemes, the body regulates the tariffs and conditions that are applicable to the cover they provide, and also acts as a moderator if a dispute should arise between a particular fund and its members.

Each fund will normally offer a number of different products, and each one is tailored to meet the likely healthcare needs and affordability of a particular demographic, such as family groups, single parents, and individuals. The extent of the financial support applicable varies from fully covering certain costs where these conform to the accepted norms, to covering the bulk of the cost while leaving the member to pay the balance in other cases. Naturally, there are also limits to the amounts that may be claimed for the various services covered in a given year, and these will be defined in the fund’s terms and conditions.

T&Cs, however, are often shrouded in technical and legal jargon that is easily misunderstood, and can make it difficult to be sure of just what some medical schemes actually cover. Aware of such difficulties. KeyHealth has compiled a selection of products that are simple to understand while also providing some valuable extras that are not offered by rival funds.