By: Farnaaz Ally | Date: May 20, 2013 | Categories: Medical Aid, Recent Posts

As a medical aid advisor, I am confronted daily about member’s confusion regarding medical aid. Apart from medical aid being an integral part of our lives, members need to fully understand specific aspects that are critical when choosing a medical plan. It is also beneficial to understand the scheme better to ensure your plan is managed well.

1.      Hospital Cover

Members need to ensure they choose a plan that would cover their major hospital expenses, when it is required. This risk portion is too big for a member to cover hence the need to choose their plans appropriately. (Ensure you are charged medical aid rates). It would not be appropriate to choose a less value of cover for a huge family, hence the need to be thoroughly informed prior to making a decision.

2.      Co-Payments

Certain schemes impose co-payments this is not refundable by the scheme, and members need to be aware of it. (Always request for generic medicines at pharmacies)

3.      Benefits vs. Premiums

There are many medical schemes available and with the help of a broker, the most suitable plan can be effectively selected to meet the member’s requirements, commitment to premiums. The hospital cover is not negotiable; however, the Savings portion is, so ensure it is applicable to your personal requirements.

4.      SAMA (South African Medical Association) Rates

GP’s & other doctors are allowed to charge higher rates, however if they charge the different rate, medical aid scheme will only pay the medical aid portion of it, resulting in you paying the doctor the difference. Some doctors charge interests, but it is not covered by the medical aid, that is for the member to settle.

5.      GAP COVER

Certain schemes have an independent Gap Cover option that is available to all medical aids plans as an add-on option. It is available at an affordable amount. This is especially beneficial when the primary choice of scheme does not cover certain accounts in full, the difference can be claimed from the Gap cover. There are terms and conditions that apply on this option as it is very affordable. There are also schemes that offer Gap cover at no additional costs, but members would need to apply for this cover, as it is only applicable for in-hospital procedures.

6.      3-Month Period

Accounts and receipts must be submitted to the medical scheme within a three-month period, i.e. from the date of service. If it is not submitted during this period, it would be regarded as a stale account and the member would be liable for the payment.

7.      Follow Up/Feedback

It is always best when you consult with any medical practitioners, you must ensure that the account is received and submitted to the medical aid for payment. The medical practitioners generally submit on a monthly or forth-nightly basis to the medical scheme for payment. They may even send it to the member directly. It is important to ensure the process is followed up to ensure the account is settled.

8.      Option Plan Change

Medical Schemes has an open period, which is normally at the end of the year to change options. Members are able to move to either a higher plan or a lower plan one.

9.      Disclosure of Information

Members need to ensure that when they are applying for new membership at a medical scheme, they must disclose their full medical history; omissions will result in termination of membership.

10.  Chronic Cover

Most schemes cover between 27 to 60 chronic conditions hence it is best to ensure that a member is guided correctly prior to joining the scheme.

11.  Can’t be Refused Cover

No medical scheme can refuse a member entry to the medical aid.

12.  Late Joiner Penalty

Over the age of 35 years, members that have not been on a medical aid will have a later joiner penalty fee applied for every year that they did not have cover. This has no end period; it would be added on to the normal month premium. The penalty can be anything from 5 % to 75%.

13.  Pre-Existing Condition

Members with pre-existing health conditions will have an automatic 12-month waiting period on that specific condition. If the member is pregnant and she wants to join the medical aid, the scheme will not cover her expenses until after the baby is born.

14.  Waiting Periods

Medical schemes generally impose a 3-month general waiting period for new members. The underwriting department at the medical scheme makes the decision

15.  New Applications

When an individual wants to join a medical scheme, the requirements may vary according to the different medical aids, however some of their requirements are: payslips (3months), bank statements (3months), identity copies or birth certificates for the members that want to join, marriage certificate as well as membership certificates.


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