Medical Aid Plan - What Hospital Plans Do Not Cover

What Hospital Plans Do Not Cover

 Many people opt for hospital plans because they simply cannot afford comprehensive cover or they feel that they are healthy and fit and therefore do not need to pay for expensive comprehensive plans. Hospital plans are designed to make provision for medical treatment in a hospital, not for the cost of day-to-day medical treatment, dentistry or optometry.

What Hospital Plans Do Not CoverMany medical aid schemes say that their hospital plans fully cover hospital treatment but consumers need to be aware that this is not always the truth. Before choosing a specific plan, it may be useful to consider the following factors:


  • Many hospital plans promise a hundred percent cover for treatment in hospitals. What they do not point out clearly sometimes is that they will only pay a hundred percent of the approved medical aid rate. There can be a vast difference between this rate and the actual charges of the hospital, the doctors and the specialists. In many cases the final bill is as high as four times the approved medical aid rate.
  • Some hospital plans include emergency transport to a treatment facility, but not all of them. It is important to check.
  • Hospital plans are not designed for providing cover for everyday medical expenses. Some plans offer rudimentary cover for the treatment of certain conditions but the amount of cover forthese benefits is usually limited.
  • Some hospital plans make provision for covering the cost of take-home medication after hospital treatment but many others do not.
  • Most schemes require their members to make use of only those hospitals, pharmaciesand doctors that are part of their networks of approved service providers. If such limitations are unacceptable it may be better to look at a different plan.
  • Most hospital plans do not provide any cover if a medical emergency occurs outside the borders of South Africa. In such a case it may be necessary to take out special insurance that will cover emergencies when traveling abroad.
  • In some cases members are able to upgrade from a hospital plan to another, more comprehensive plan when circumstances change, but some schemes do not offer this option. It is better to opt for a flexible plan from the word go.
  • Many hospital plans have exclusions, meaning that certain treatments and procedures, even in hospital, are not covered.
  • Most medical schemes require their members to obtain approval from the scheme before admittance to a hospital. If this is not done the member can be held liable for the cost.
  • Many medical aids will only pay for a certain time in hospital. They may, for example, rule that no more than three days in hospital is necessary for a specific procedure and they will only pay for that time unless a detailed justification is provided by the doctor in charge of the case.

The fact of the matter is that there is no such thing as a hospital plan, or any medical aid plan for that matter, that offers unlimited cover. Members must study the terms and conditions of their hospital plans and they should make sure that they keep to them when accepting medical treatment. © Medical Aid Plan



Medical Aid QuoteNOTES:

Your medical aid quote will include options to suit your pocket. Please ensure that the cover you select is exactly what you need and that you understand exactly what insurance you are buying. Do not hesitate to ask questions about the medical aid or hospital cover you choose.