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Choosing a Medical Aid in South Africa


 

  

  

Is Your Medical Aid Sufficient Health Cover?  

Many people live under the illusion that they are fully covered for their medical expenses and only find out that they are not when they are faced with massive bills.Health Cover Most members of medical schemes cannot rest assured that they will be able to claim all medical expenses from their schemes: in most cases there will be a self-payment gap. 

When will my medical aid not be sufficient? 

There are several reasons why members may be required to pay certain treatment cost themselves. The most important of these are as follows: 

  • If your medical savings account is exhausted you become responsible for further expenses.
  • Most plans have treatment limits. If you exceed this limit you will be held liable for further expenses. You need to make sure that you are fully informed about the limits set in your specific plan.
  • Your medical practitioner may charge more than the rate that will be paid by the medical scheme.
  • The scheme may refuse your claim if they are of the opinion that your condition does not feature on the Minimum Benefits list. There are approximately 300 conditions on this list and it may be wise to check with the medical scheme before undergoing treatment.
  • You may have exceeded to limit for the management of certain conditions such as asthma and various cancers.
  • You may have decided to opt for treatment that is specifically excluded by your medical scheme and which is described as “self-payment”. In some cases the scheme will pay only a portion of the cost. It is always a good idea to check with the scheme before agreeing to any treatment.
  • If you suffer from cancer the chances that the scheme will meet all the costs are very slim indeed.
  • If you require synthetic body parts such as will be the case with hip replacements, heart transplants or if you use devices such as wheelchairs then you will have to accept the fact that the scheme will not pay for top-of-the-range models.
  • Very few plans make provision for organ transplant. If you require a transplant you should check with the scheme immediately.
  • Patients that require prolonged rehabilitation often find that there schemes will only cover the cost for a short period. 

What can I do about it? 

There are a number of steps that will help to lessen the shock of unexpected medical expenses: 

  • Make sure that you study the terms and conditions of your specific plan very carefully. It may also be wise to choose a plan that can be upgraded when circumstances demand such a step. If you have questions, ask your medical broker or your scheme to explain the uncertainties.
  • Always check with the medical scheme before visiting a specialist or hospital or before agreeing to treatment and surgical procedures.
  • Think about increasing the size of your medical savings account. In this way you can build up an emergency fund that will be extremely helpful when you are faced with major medical expenses such a cancer treatment or organ transplants, for example.
  • Do not be intimidated if you suffer from any of the conditions that are on the Limited Benefits list. Your medical scheme has to cover the cost in full. If a dispute arises you are entitled to approach the Council for Medical Schemes.
  • It is against the law to belong to more than one medical scheme, but nothing stops you from purchasing additional health cover through medical insurance policies. Many insurance companies also offer gap cover. © Medical Aid Plan