Hospital Plan vs Comprehensive Cover

Your medical scheme membership fees have gone up again. Is it worth it?

This is a question many younger, healthier people are asking, especially those who are buckling under bond and car repayments, on top of other expenses. With economic recession and its “aftershocks” still looming, many members of medical schemes are wondering whether they should cancel their membership or at least reduce this monthly expense. But, is this possible, without losing their cover?

The first “grudge expense” most people want to cancel is their medical scheme contribution. This contribution forms a big part of their budget and sometimes seems unnecessary.

Mr Marcel du Toit, chief executive of Optivest Health Services, says consumers should rather not cancel their medical scheme contribution if they are starting to feel the pinch. “First consider other possibilities, such as whether you can switch to a cheaper option in your current scheme.”

“Saving a few rand on your contribution could mean more cash in your pocket at the end of the month. If you are currently on a comprehensive plan, your family is fairly healthy and your daily expenses are not too high, it might be a good option to switch to a hospital plan or a network plan until economic conditions have stabilised.”

If your finances are tight and you have a choice between a hospital plan and no medical cover at all, the hospital plan is obviously preferable.

So, how does one choose between a basic hospital plan and a full comprehensive option?

Keep in mind the main differences between the two options:


Hospital Plans

  • Cover accounts from service providers only while you are in hospital (100%, 200%, 300% or 400% of NHRPL)
  • You are responsible for own out-of-hospital and day-to-day expenses
  • Are mostly cheaper than comprehensive plans.

Comprehensive Plans (Full Cover)

  • Cover almost all medical expenses (subject to the rules of the scheme)
  • Have benefits for in-hospital and day-to-day expenses (subject to the rules of the scheme)
  • Are recommended if you require regular medical treatment (which is not a PMB) or suffer from a particular chronic condition.

Basic questions to ask to make this choice easier concern the following:

Affordability.  What can you afford?

Evaluate your and your dependants’ state of health. Do you use chronic medication? Any planned procedures?

Type of cover needed. Choose the best medical scheme for your specific needs. Take a look at the benefits the different schemes offer. If you have eye problems, for example, you won't choose a scheme that only allocates R200 per year for glasses. If you're very healthy, it could be to your advantage to take a scheme with low day-to-day benefits, but good hospital coverage.

Read the small print. Some schemes may look good on paper, as they seem to pay 100% of claims, but take note of that 100%. Is it only 100% of the NHRPL tariff and do they have overall limits and exclusions? Remember that most medical providers charge a higher tariff than the NHPRL rate.

Which option will be a saving for you? Add up all your day-to-day (out-of-pocket) expenses on medical bills annually. Sometimes these will offset the difference between the Comprehensive Plan and the Hospital Plan, and it will be more beneficial for you to upgrade to a comprehensive plan.

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