Beware – Medical Aid Payout Ceilings

There is so much information one needs to know when investing in medical aid plans. You definitely need to beware that medical payout ceilings are in force with medical aids. And that applies to hospital plans or any other plan your medical aid has on offer. 

What is the definition of payout ceilings?

In laymen’s terms, it means the uppermost level. Each medical scheme has a payout ceiling or limit of how much they will pay for certain procedures. These limits also vary from one medical aid to the next.

Who is most influenced by payout ceilings?

Generally people who have a dread disease, are disabled or have any conditions where they need ongoing treatment like cancer for example. The medical company will only pay out claims for the specific condition up to the company’s ceiling.

A list of these ceilings or sub limits will be given when you make an application to a new medical aid. Always make sure that you have sufficient cover if you fall into the category of needing extensive treatments for specific conditions. Even if you are healthy, look into your family history. See if there are possibilities of certain conditions that could arise in your future.

Going back into our family history we found that Asthma, Stroke and Coronary Heart Disease were prevalent. So we looked at the cover our medical aid would give in case we inherited such conditions.

The elderly are influenced by these ceilings as well because the older you get the more sickly you become and are more vulnerable to falls that need in-hospital care and operations.

Other information you need to be aware of

Should your medical plan not have sufficient cover when you first join, you can upgrade later. Let’s say you develop an ailment that is not covered on your existing plan and you upgrade. Well then, make sure about how long your waiting period will be, for that specific ailment, when you upgrade.

The limits imposed are not always annual but can work in cycles. As an example, you are Asthmatic and need the regular use of a nebuliser, your plan may pay up to a certain amount over a three year period.

So if your medical plan limit is R590 in a three year cycle, you are only able to use R196,66 of the benefit per year (R590 divided by 3 years).  When broken down it is really not very much if you need a nebuliser on a fairly regular basis. Some plans have five year cycles for certain things as well. These kinds of limits are usually imposed on medical appliances, like a wheelchair, that you may need for certain conditions.

In Conclusion

• Make sure you do some homework as to the cost of certain conditions if you have a family history of major medical conditions. 
• Always check what your ceilings or limits are when applying or changing medical aids and be aware of any sub limits that are present, as well as whether the limits are annual or work in cycles.

All info was correct at time of publishing