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Understanding your Medical Aid Membership – Its Benefits and Limitations

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Given the steady decline in South Africa’s overburdened and under-funded state healthcare service, reliance on the private sector has continued to increase. The fate of government hospitals and clinics can be directly attributed to escalating costs far-exceeding the funds raised by the national health insurance scheme (NHIS). However, since those same cost escalations apply equally to the private sector, the vast majority of its patients must rely on a medical aid membership as the means to ensure they are able to cover their healthcare-related expenses.

When the first private clinics opened for business, financial assistance to patients was provided by short and long-term insurers, and offered the benefit of a fixed sum payable should a contingency arise, in the manner typical of general insurance practice. It quickly became apparent that a more specialised type of cover, in which the sums paid to claimants were more in keeping with the actual costs involved, was necessary.

The niche was quickly filled by the formation of a new type of organisation known as a medical aid scheme. Offering membership in exchange for a monthly premium, these schemes provide a detailed list of all the services covered, and the maximum sums that may be claimed for each of these during the contracted period.

Depending on the particular product, cover might apply to just a single individual or, where relevant, extended to include any dependent family members in exchange for a nominal, per capita increase in the premium. Whether you are the main member or a dependent, certain restrictions may sometimes apply. For example, a new applicant could be required to wait for up to three months before receiving benefits if he or she has no record of recent membership in another medical aid scheme. Also, those with a pre-existing condition could be precluded from submitted related claims for up to twelve months,

These waiting periods are approved by the Council for Medical Schemes (CMS), but both may be subject to exceptions, and these may need to be clarified before signing up. Also, the stated maximum periods may be reduced at the discretion of a scheme’s trustees. Whatever may be the case, the important outcome of this legislation is that none of the nation’s eighty or so functioning medical aid schemes have the right to refuse membership to those with pre-existing conditions, but only to enforce a waiting period before accepting any claims that may arise as a consequence of that condition.

Incidentally, once you or your dependent is fully covered, since the establishment of the CMS in 1998, every scheme in South Africa is obliged to include cover in all of its products for certain prescribed minimum benefits (PMB). The list is extensive, but most significantly, it includes full cover for all diagnostic testing, treatment, and care associated with twenty-five chronic illnesses. The list includes conditions, such as asthma, diabetes, epilepsy, hypertension, multiple sclerosis, schizophrenia, and bipolar disorder.

The introduction of PMBs has done much to make private healthcare more affordable, and to safeguard the health of those who require continuous care. At KeyHealth, we provide a range of affordable medical aid membership options with several unique core benefits at no extra charge.

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