Medical Aid Plan - Top 10 Facts About Medical Aid Schemes in South Africa

Top 10 Facts About South African Medical Aid Schemes


Top 10 Facts About South African Medical Aid Schemes



  1. 1. There are both open and closed schemes in South Africa. Among the ninety three registered schemes, the vast majority is accessible only to employees of certain organizations, such as the Gems Medical Scheme which may only be joined by government employees. You should therefore make a list of all the open schemes; schemes that may be joined by anybody. Discovery Health, Sizwe Medical Aid and Momentum Health are just some examples.
  2. Open medical schemes may not refuse an application for membership. This is subject to the condition that the new member accepts the rules and that he pays his monthly premiums, of course. These schemes are also obligated to accept the dependents of the new member as members too. It may be wise to ask for a detailed quotation before entering into any agreement with a medical scheme.
  3. The option of joining a scheming personally or through a medical broker is your choice. No scheme can insist that you use a third party.
  4. You may never belong to more than one scheme at a time. It is against the law.
  5. All matters relating to medical schemes and the industry as a whole are regulated by the Council for Medical Schemes and they are empowered to receive and manage complaints.
  6. The Medical Schemes Act of 1998 was promulgated on the first of February 1999. Every aspect of the industry is regulated by this act. Consumers would be wise to study the act.
  7. One of the most important components of the act is that it compels all medical schemes to provide cover for all conditions listed as Prescribed Minimum Benefits. This list contains approximately three hundred conditions, among which twenty seven chronic illnesses. Not only do the schemes have to provide cover for all conditions on this list, but such cover must include diagnosis, hospitalization where necessary, on going treatment and medication.
  8. It is important to understand your own responsibilities. There are cases where you are required to obtain approval from the medical aid prior to treatment or hospitalization. In many cases you are obliged to use only approved service providers. Most schemes will not entertain claims that are incorrect, incomplete or without the relevant prescribed codes. It is always better to seek clarification from the scheme if there is the slightest uncertainty.
  9. There are instances where you will be liable for paying a part of the cost of medical treatment. This is especially true if you fail to make use of designated service providers or if you insist on using medication that is not on the approved list of the scheme.
  10. The biggest medical; scheme in South Africa is the Discovery Health Medical Scheme. Among the other large schemes are Fedhealth, Bonitas medical aid, Liberty, Sizwe Medical Fund, Momentum and Bestmed. © Medical Aid Plan

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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.