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What Are the Benefits of a Medical Scheme?


The shortest and perhaps the most significant response to this question is that most people with this kind of health insurance would say that peace of mind should be ranked high on the list of benefits of enrolling in a medical scheme. As a member, this means that, should you or one of your family members, be involved in an accident or develop a serious illness, the services of the appropriate healthcare professionals are instantly available and at a fraction of the price that would be required of a non-member and, in many cases, at no cost at all. While treatment at a state hospital may be free or offered for a nominal sum, the facilities at their disposal are extremely limited by comparison, as is the availability of trained staff. As a result, even attention to urgent cases is frequently delayed.

More specifically, however, the benefits of a medical scheme are those listed in its product prospectus. These, in turn, will be subject to any specific terms and conditions that may have been set by the particular cover provider. Typically, each of a scheme’s options will indicate the maximum sum that can be claimed by a member for each of the contingencies listed. These limits may apply to a single event and to the total period of cover. Cover is limited to a 12-month period, after which membership must be renewed, and on renewal, both the prevailing terms and premium price could be subject to change.

To some extent, the range of benefits of a given medical scheme will be determined by the amount the member is willing and able to contribute to the monthly premiums. Some, however, are not negotiable, and are independent of the premium price. Since the formation of the Council for Medical Schemes (CMS), in 1998, all medical aid products are required to include what are known as Prescribed Minimum Benefits (PMB). This, for example, provides for those who may be suffering from one of 25 named chronic diseases, as well as for all emergency medical conditions and a set of 270 medical conditions defined under the Act of 1998 and defined as treatment pairs. Examining physicians must base their diagnoses on symptoms alone, irrespective of the particular circumstances that might have led to the illness or injury.

For many members, the PMBs alone can be invaluable. As basic benefits of all medical scheme products apart from the hospital plan, which normally only applies to members while they are hospitalised, cover includes all costs relating to the diagnosis, treatment, and care of the listed conditions, throughout the membership period.

The types of schemes are: open and closed or restricted. The former is open to all and aimed at the self-employed, professionals, and those without access to a closed scheme. Closed types provide cover to defined groups, such as the employees of a large company or a specific industry, or the members of a professional body. They all benefit from group rates, so their premiums are lower than those offered to individuals, while employers normally contribute a portion of the premium as well.

That the benefits of being a member of a medical scheme are invaluable goes without saying. That KeyHealth offers the best value for money is equally true.