Understanding How Medical Aids Pay Claims

January 7, 2013

Here is an introduction to how medical aids pay claims.

One of the most common complaints received by all medical aid schemes relates to pay-outs. Medical aid plans are often complex and consumers do not always take the trouble to familiarize themselves with the terms and conditions.

This cause conflict when the member wants to claim for treatment and the medical scheme refuse because there is not cover for the specific treatment or procedure  in the plan in question, or the member has reached his limit.

It is vital to understand exactly what it is that a specific plan offer and what the procedures are to make a successful claim. It also helps to understand the ins and outs of how medical aids pay claims.

How Medical Aids Pay Claims – Understand the terms and conditions

There is no such thing as an unlimited medical aid plan. All plans have certain limits and the benefits How Medical Aids Pay Claimsoffered by the various plans can differ widely. In essence, most comprehensive plans have some common characteristics:


  • All comprehensive plans offer in-hospital cover. Some medical schemes require their members to make use of a prescribed network of hospitals, however. In most cases members must obtain prior approval from the scheme. In-hospital cover does not necessarily cover all the costs of hospitalization. In many cases the scheme will pay medical aid rates to the hospital and the attending medical experts. It is vital to understand that the charges of the hospital and the medical specialists are almost always much higher than the approved medical aid rate. The member will have to pay the difference between the actual charges and the medical aid rate. It is an unfortunate fact that they actual charges are often as high as four times the medical aid rate. Important: you can get gap cover insurance for this. Go here for more information.


More Info About How Medical Aids Pay Claims

  • Most comprehensive plans make provision for chronic medication. In this instance, too, medical schemes often require members to obtain their medicines from an approved source. Many medical schemes negotiate specific rates with suppliers. Scheme members that do not adhere to these terms could be responsible for the cost of the medication or they may have to pay the difference between the actual price and the negotiated price.
  • Comprehensive plans also make provision for day-today medical expenses. This is the area of cover that most often lead to disagreements and complaints. Day-to-day cover is typically divided into various categories, such as dental care, preventive treatment and optometrist services amongst others. Each of these categories makes provision for limited claims per incident and per year. In addition, there is often a limit to the amount that can be claimed by the family as a whole. Some funds make provision for a savings plan that can be used to pay for shortfalls.
  • Most plans also offer additional benefits such as emergency treatment at a casualty unit, transport and transfers, trauma counselling and even drug and alcohol dependency treatment. These benefits also carry certain limits.


How Medical Aids Pay Claims – Conclusion

Members of medical aid schemes must make sure that they are informed regarding the cover that they and their dependents enjoy. It is the responsibility of members to manage their medical plans responsibly.

If the benefits do not suit the needs of the family, a different plan should be considered or the medical scheme can be asked to upgrade the existing plan to another plan that has higher limits or that offer more benefits.

All info was correct at time of publishing