Beware of Medical Aid Payout Ceilings

Beware – medical aid payout ceilings are a genuine factor that can harm your financial health.
Beware of Medical Aid Payout Ceilings 

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 a 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 amount due.

Who will these ceiling rates influence most?

  • 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 themselves.
  • 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 cover?
  • Some schemes offer a medical savings account that covers some of these costs.
  • You might receive above threshold benefits from your 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 costs?
  • Consider purchasing additional Gap Cover; that is designed to cover you in the instance where medical service providers charge more than the ceiling levels.
  • Study the limits your scheme; should you reach the limits it might be wise to upgrade to a higher medical aid option.
  • 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 needs.

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 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.



Latest Posts

  • What Medical Schemes Offer and Do Not Offer

    Medical schemes in South Africa overview including a list of the biggest medical aids and the different plans available and their limits. Fill in the form and receive a comparative quote by email.

    Read more

  • What is a Medical Scheme

    What is a medical scheme Find all the answers here about medical aid schemes in South Africa and gap cover. Fill in the form and receive a comparative quote by email. Act now!

    Read more

  • Momentum Medical Aid

    Momentum Medical Aid information that South Africans can use to make informed decisions about medical scheme and hospital cover choices.

    Read more

Share via
Copy link