Top 10 Gaps in Medical Aid
Cover and How to Fix Them
The vast majority of people that are members
of medical aid schemes have experienced the frustration of not being covered, of having reached
the yearly limit or by having to pay a portion of the bill. Just about every plan offered by the various
medical schemes contains some gaps. Knowing about them can help you to avoid them. Here are the Top
Exceeding the limit set to a
specific benefit is the most common problem. Medicals schemes categorize the various benefits and in
most cases there is a limit on each category. In addition, the plan may have an overall yearly limit,
regardless of the claims made against any specific category. The only way to avoid this particular
problem is to obtain better cover or to increase the size of a medical savings
Many medical schemes will only pay the
approved medical aid rates. Even if the plan specifies “full” cover, this does not mean that all
the cost will be paid by the scheme. The reality is that most doctors, specialists and hospitals charge
significantly more than the approved medical aid rate. The difference is for the pocket of the member.
The solution is to only use those doctors that are contracted to the medical
No medical aid may refuse cover for any condition that is on the
Prescribed Medical Benefit list. To do so would be breaking the law. If
the scheme refuses cover for any of these conditions it is the right of the member to ask for redress
and to insist on treatment.
Many schemes have a limit on
conditions that require managed care. Most schemes have specific
policies for the management of diseases such as cancer, hypertension and asthma, for example. The only
solution is to ask the attending physician to outline the treatment plan in detail and to submit this
plan to the scheme for approval and to find out exactly what the scheme will
Many schemes list specific conditions and
procedures for which a co-payment is required. These are conditions and procedures that are
deemed to be either unnecessary or ineffective. Examples include hip joint replacement, wisdom teeth
removal and gastroscopies. The solution is to find out from the medicals scheme whether such procedures
will be covered and if not, what the co-payment will be.
Cancer patients often find that their
schemes do not cover the full cost of treatment, even if the condition is on the Prescribed
Minimum Benefit list. Most schemes have three levels of cancer cover and it is important to determine
just which cover your plan has. It may also be wise to purchase additional medical aid cover.
Many medical aid members are disillusioned when their
medical savings accounts are exhausted long before the end of the
year. The only solution is to increase the monthly savings or to purchase additional
Most members of medical schemes will not
receive top of the range replacement body parts such as hip joints, or appliances such as
wheelchairs. Only a basic model will be paid by the scheme. For better quality, it is necessary
to keep the medical savings account as high as possible.
Many members find, to their shock, that they are
not covered for serious matters such as organ transplants. It is
vital to study the exclusions in any plan before making a final decision. Cosmetic procedures are
excluded from just about every medical aid plan.
Few plans cover the cost of
rehabilitation, such as may be necessary after surgery. Again, it is necessary to study the
exclusions that form part of the proposed plan and to rather select a different plan if such cover is
foreseen or wanted.
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