Medical Aids in South Africa - Too many, too complex.

Medical Aids in South Africa – too many, too complex

We can all agree that your health is not something to be taken lightly, placing great importance in the process you follow when choosing the right medical aid for you and your family. This article provides you with an overview of the South African medical scheme landscape. By the end you will have a much better idea of what to look for in a medical aid.

With over 147 private medical options from 21 Open Medical Schemes in South Africa, choosing one can be confusing and time consuming.

Medical aid may feel like a grudge purchase, especially since private medical aid premiums could take up to 10% (or more in some cases) of your monthly salary. It’s a difficult concept to grasp when everyone in your family is healthy, but you should try to see your medical aid as an investment for future health. For this reason, it is important not to base your medical scheme decision on price alone. Settling for the cheapest medical aid you come across is not a recommended strategy. There are various factors to consider in order to make an informed decision.

As a member of a medical aid you may expect cover for the following healthcare services:

  • Day-to-day benefits: GP and dentist visits, specialist consults, as well as examination, diagnosis preventative care, and treatment of diseases.
  • Medicine: Chronic (e.g. diabetes) and acute medication (e.g. colds and flu); and
  • Major expenses: Emergency hospitalisation, ambulance services, maternity benefits, and mental health management.

Unfortunately, not all medical scheme options are equal. There are four different types of plans that you could choose from. Each has its own list of what’s included and what’s excluded. Here is a basic guide of what to expect:

  1. Network options – For individuals and families with young children that need to visit the doctor more often but can’t afford a comprehensive medical aid. This type of plan includes basic day-to-day cover at affordable prices with specific network providers and in-hospital expenses submitted by network service providers. Note: the network of providers differs from scheme to scheme.

  2. Basic hospital plan – Best for active, healthy families who take responsibility for their own day-to-day health but want the peace of mind that hospital expenses will be covered. This type of plan includes in-hospital expenses submitted by service providers and excludes emergency ward treatments and any day-to-day medical expenses.

  3. Hospital plan with savings – A great option for individuals and families wanting peace of mind that hospital expenses will be covered and those wanting a medical savings for day-to-day medical expenses in addition to hospital cover. Here you pay a fixed monthly amount into a medical savings account. The full amount becomes available in advance for medical expenses incurred for that year. This type of plan includes in-hospital expenses submitted by service providers and day-to-day medical expenses.

  4. Comprehensive plan – This option is for Individuals and families that want comprehensive cover without a savings benefit. It includes almost all medical expenses, in-hospital benefits, day-to-day medical expenses and chronic medication and excludes a medical savings account.

As you can see, the medical aid landscape in South Africa is complex. Therefore, before shopping for medical aid quotes you should review your family’s current and future health status, age of family members to be covered, unique healthcare needs and how important the healthcare services listed above are for your specific situation. In addition to this, you will also want to consider the following:

  1. Restrictions (cases or situations that the scheme won’t cover)

    Again, each medical aid scheme and option is different. As an example, most medical aid schemes won’t pay for cosmetic surgery (except for emergencies i.e. accidental disfigurement). They also don’t cover anything relating to obesity management, as obesity is seen as a lifestyle condition that can be managed by the patient. These are just two examples. Not all medical aids have the same benefits and exclusions, some cover conditions others won’t. Restrictions are dependent on the type of plan you chose and is often linked to how much you spend. Find out about these exclusions upfront, before making your choice.

  2. Annual funding limits

    Annual funding limits apply to all medical aids and refer to an, often, set amount paid by the medical schemes for the member’s in- and out-of-hospital expenses. Nobody ever thinks they are going to end up in a hospital but in the event that it happens, you wouldn’t want unforeseen hospital expenses to set you back financially. Having good hospital benefits could be seen as the most important decision regarding your choice of medical scheme option. In addition, you may consider adding GapCover to your plan for even more financial protection against in-hospital specialist bills.

  3. Network limitations

    Most medical schemes have an established working agreement and negotiated rates with a specific network of health practitioners (doctors, specialists, dentists, and hospitals) to treat its members. Choosing to join a network option can save you on monthly premiums, however, note that you could be penalised or not covered by your medical scheme if you use a health practitioner outside of this network.

  4. Exclusions

    When joining a new medical aid scheme, consumers often overlook factors such as being refused membership based on your age or current medical status. Medical schemes reserve the right to exclude pre-existing medical conditions from cover for the first 12 months of membership. This can feel like an eternity for someone that is in desperate need for medical cover. In most cases, the first three months after joining a medical scheme is considered a waiting period during which a member cannot claim for any medical expenses – consider this when switching form one scheme to another. Also note that medical schemes have the power to impose a ‘Late joiner fee’ on new members aged 35 and older. (This only applies if the person in question was not previously a member of a medical aid or those who have not belonged to a medical aid scheme for a specified period prior to April 2001.)

Medical jargon is confusing

It is imperative that new and existing medical aid members familiarise
themselves with the terms, conditions and exclusions of their chosen medical
aid benefit option before signing any paperwork. Each medical scheme has its
own set of rules and as a consumer, navigating and understanding those rules
and the accompanying jargon can be next to impossible without expert help; you
could very easily make the wrong choice. It is therefore recommended that you
use an expert comparison site such as  to help you find and compare
medical scheme benefits and price. Not only will it save you time, but it will
also give you options that you may not have even considered when undertaking
your own research. You don’t know what you don’t know, so turn to the experts
in the industry to help. Best of all, any comparisons done on the site are free.