Beware of Medical Aid Payout Ceilings
Beware – medical aid payout ceilings are a genuine factor that can harm
your financial health.
Ideally you should find out before you sign up with a medical aid or a
hospital plan if their definition of "payment in full" actually means that or if it means they will pay out the
full amount according to their own assessment of what the amount should be.
So when you join a medical aid please ask about payout ceilings. Often
certain procedures, consultations and medications have annual limits.
What is a payout ceiling?
Medical aid schemes place a limit on the amount of money you can claim per
incident. They only pay up to certain amount of the costs concurred. This is the uppermost medical aid in South
Africa will pay. It is called the medical aid rates. Some medical aids pay up to 100% of medical scheme rates where
others pay up to 250%.
How do these rates affect you?
Some private specialists and hospitals can charge up to 300% of the
medical aid rates, say for instance your medical aid rate has cover of 100%; you will be liable for the rest of the
Who will these ceiling rates influence
- People with dread diseases like heart conditions and cancer that
needs a lot of medical procedures and medications are some of the most vulnerable to these ceilings. The scheme
will only pay a certain amount for these conditions and the person claiming will have to cover the rest
- Your medical scheme will provide you with a list of ceiling amounts
when you apply for a medical aid plan, make sure the plan you choose has sufficient cover especially if you
have a dread disease family history, this also goes for chronic diseases.
- The elderly are also greatly affected by these medical aid claim
ceilings, as you get older the chance of illness increases marginally.
- How do medical aids help with ceiling
- Some schemes offer a medical savings account that covers some of
- You might receive above threshold benefits from you fund, to assist
with ceiling rates.
- Some schemes carry over unused funds to the next financial year. You
do need to confirm this with the scheme though.
- Many schemes have made deals with specific service providers, these
providers will charge you the rates they agreed with the scheme.
- How to ensure you are protected against unplanned medical
- Consider purchasing additional Gap Cover; that is designed to cover
you in the instance where medical service providers charge more than the ceiling
- Study the limits your scheme; should you reach the limits it
might be wise to upgrade to a higher medical aid
- Contact your medical aid before you undergo extensive medical
procedures, that way you will be sure what you are letting yourself into.
- When you choose a medical aid plan affordable medical aid might not
be the best option to cover your medical needs especially if you have advanced medical cover
In conclusion it is important to beware of medical aid payout
ceilings. Make sure you have sufficient cover and additional options available like gap cover to ensure
you will not suffer financially due to high medical care costs. © Medical Aid
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