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Understanding What Hospital Plans in South Africa Include and Exclude


Hospital plans are the most affordable form of medical aid in South Africa. However, one must appraise them carefully as they may not be suitable for everyone. The concept of medical insurance is not new and was first introduced in the USA during the1950s to assist with the high cost of surgery and treating chronic illness. On the local scene, insurance companies followed suit with the hospital cash plan – a policy that paid a pre-agreed cash sum for each day confined to a hospital. However, only the formation of dedicated medical aid companies during the ’60s enabled adequate financial support with costly private healthcare services for those who could not otherwise afford them.

Sadly, the once widely envied state health service has fallen foul of rising costs and increased demand due to chronic underfunding. Furthermore, the government’s proposed plan to introduce a compulsory contributory scheme similar to Britain’s national insurance fund to cope with the shortfall seems unlikely to culminate anytime soon. With more and more South Africans becoming dependent upon the private sector for treatment, the need to provide more affordable medical aid products is paramount. For many, the solution is one of the industry’s hospital plans.


How Do Hospital Plans Differ From Other Medical Aid Products?

The clue is in the name. Rather than attempting to assist with all of a member’s annual private healthcare bills, these products are primarily intended to help with the most expensive medical contingencies – those that invariably occur whenever the beneficiaries find themselves hospitalised. Without such help, private patients who may require an emergency appendectomy or treatment for injuries incurred in a motor vehicle accident could face a staggering final bill that might force them to take a high-interest loan or even file for bankruptcy.

When launched initially, these plans were aimed at younger, unmarried individuals in good general health but with a limited income that precluded access to fully-comprehensive medical aid products. When not in the hospital, basic plans do not assist the member with GP visits, prescription charges or other day-to-day healthcare services. However, rising costs and recession have forced more South Africans to seek cheaper private healthcare coverage. Consequently, medical schemes have developed various extensions of the basic plan to include help with some of their out-of-hospital medical expenses to ensure affordable products that meet most members’ established and anticipated private healthcare requirements. The extent of these additional benefits will reflect in the premium price, but these augmented hospital plans remain a very affordable option.


Some Examples of Augmented Hospital Plans

Assistance with the hefty bills arising from in-patient treatment is central to even the most comprehensive medical aid plan and is most members’ primary concern. Legislation introduced by the Medical Schemes Act 131 of 1998 requires medical aid schemes to include certain prescribed minimum benefits (PMB) in all their products, including the most basic hospital plans. These include diagnosing and treating 26 chronic diseases, such as asthma, epilepsy and diabetes, so those most in need are entitled to assistance with these ongoing expenses. However,  many families require help with other out-of-hospital medical costs. KeyHealth offers various extensions to the basic plan to assist them.

  • Essence is our entry-level option. While still highly affordable, this product combines all the benefits typically included in a basic plan with some potentially valuable additions. To unlimited hospital cover, we have added various out-of-hospital services at cost for patients with PMB entitlement. These include GP visits, specialist consultations, radiology, prescribed and OTC medication, optical services, physiotherapy and occupational therapy.


  • The Origin option is more comprehensive. For those seeking unbeatable value for money, Origin is the answer. Unlimited hospital cover is teamed with specified day-to-day benefits, including 100% payment for those routine medical expenses discounted with Essence, optical services and conservative dentistry when charged at medical aid rates.


  • Equilibrium offers the freedom to manage day-to-day medical bills. Instead of a defined list of out-of-hospital benefits, Equilibrium is far more flexible. An integrated savings plan provides a pool of available cash that enables members to pay for whichever healthcare services they choose should they need them. Any unused savings may be carried over to the following membership year.


Choosing the Best Hospital Plan for You and Your Family

Please take the time to browse our entire product range or focus on our affordable hospital plans, if preferred. Remember, all our products include three additional core benefits at no charge.