Medical Aid Plan - Top 10 Gaps in Medical Aid Cover and How to Fix Them

Top 10 Gaps in Medical Aid Cover and How to Fix Them


The vast majority of people that are members of medical aid schemMedical Aid Coveres 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 10:



  1. 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 plan.
  2. 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 scheme.
  3. 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.
  4. 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 pay.
  5. 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.
  6. 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.
  7. 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 cover.
  8. 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.
  9. 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.
  10. 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.



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.