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Understanding How Your Medical Aid Scheme Benefits Work


Without the financial support of specialised insurers, there would be few South Africans in a position to afford the services of a private healthcare facility or a specialist. Instead, they would be forced to join the ever-lengthening queues or waiting lists that have now become the norm for those seeking state-funded treatment. Though superficially similar to the policies offered by short- and long-term insurance companies, the cover provided by a medical aid scheme is more about tangible benefits than sums assured.

When insuring a car, for example, the policyholder’s vehicle will be covered for repairs up to a maximum value, and the claimant is required to obtain multiple quotes before the insurer will nominate a service provider and authorise a repair. By contrast, when providing cover for healthcare, the insurer must provide a comprehensive list of the all various conditions, treatments, and care included under the terms of cover and the maximum amounts that may be claimed in each case. These terms, in fact, serve to define the various benefits available to the members of a medical aid scheme, and these tend to vary both between alternative schemes and the various products that each of them offers.

Generally, a given company will offer a range of five or six products, priced according to the extent of the cover provided. This will often amount to full payment for items and procedures for which the tariffs charged for the services received fall within the limits set by the insurer. Where they fail to do so or where payment of a fixed percentage of the total cost may apply to certain services under the agreed terms, the member will then be liable for any outstanding co-payment.

While generally, such outstanding amounts are relatively small and affordable for most members, it underlines the need to examine any product offered by a medical aid scheme closely, so as to be sure what benefits are, or are not included, before committing to it. Fortunately, under the terms of the Medical Schemes Act (131 of 1998), all schemes must provide cover for certain prescribed minimum benefits (PMB). These include all costs relating to the diagnosis, treatment, and care of 25 chronic illnesses, such as diabetes, epilepsy, and thyrotoxicosis.

Other changes introduced under the act ensure that nobody with a pre-existing condition may be denied cover for private healthcare. Instead, they may be subject to a mandatory waiting period before any claims relating to that particular condition will be accepted. Clearly, anyone in this position should check closely for details of any such condition that may apply to his or her medical aid scheme benefits.

Given that so many South Africans are now seeking ways to cut costs, the temptation to select cover for private healthcare based on monthly premiums is understandable. However, unless one can be certain that a chosen product meets all of the needs of the main member and any dependents, this could prove to be a false economy.

Often, even the closest scrutiny fails to reveal possible shortfalls, and this is why so many South Africans are turning to KeyHealth. With its what-you-see-is-what-you-get brand of clarity, affordable and relevant products, and core benefits not available from other medical aid schemes, it is not too surprising.