South Africa’s Top Medical Aid Schemes, Their Limits and Waiting Periods
March 17, 2017
In South Africa, there are 26 open medical aid schemes. Open means these medical aid schemes are open to anyone, while closed medical aid schemes are for specific employee groups. Here will have a look at the top medical aid schemes in South Africa.
Each of these medical aids offers different sets of benefits to choose from, depending on your healthcare needs and budget.
What they pay for – Top Medical Aid Schemes
According to the Medical Schemes Act of 1998, medical schemes must pay for the treatment of a certain list of conditions and a list of 270 procedures altogether. These conditions and procedures are the prescribed minimum benefits (PMBs).
According to the act, there are standard-rate fees for people to join medical aid schemes regardless of their health or age. There is no discrimination on the grounds of peoples’ health. The definition of dependants includes spouses, life partners and natural and adopted children. And lastly, the Act also sets out a complaints procedure for people who have a complaint against a medical scheme.
Knowing what your claim limits form an essential part of choosing the correct medical aid for your needs.
Medical aids typically cover day-to-day benefits (out-of-hospital services and visits to specialists,GPs, dentists. And allied and support professionals as well as the prevention, examination, diagnosis and treatment of diseases), medicine (chronic and acute medicines) and major medical expenses (for hospitalisation, appliances, ambulance services, maternity benefits and the management of physical and mental deficiencies).
Top Medical Aid Schemes limitations
Limitations and exclusions form part of any medical aid and are enforced in an attempt to save costs. Increases in health care and non-health costs, sometimes at rates much higher than general inflation. They require member subscription rates to increase annually.
Medical aids then try to reduce their spending by targeting non-essential health care first. But this often leads to misunderstandings and hardship. Because what’s unnecessary by one person is essential by another.
For example, you may limit to R750 000 for accident cover or exclusions on your medical aid from having cover for certain scans.
Medical aids limit their liability by financial limitations or exclusions on the cover for certain conditions or treatments.
An example of a limitation is when each family member limits to dentist work done of R3000 per year. But the limit for the whole family per year is R9000. If you are five members in the family who all want dentist work in the same year, each member will limit to only R1800.
The exclusion list in Annexure C of scheme rules deals extensively with limitations of entitlements.
Entitlements in any scheme are optional or compulsory. The prescribed PMBs cover the compulsory entitlements.
The Regulations in the Medical Schemes Act states the members get treatment for PMBs and that it must have full cover under certain circumstances.
Non-PMB conditions and entitlements are in the medical aid’s scheme rules, and limitations and exclusions apply to them.
According to Genesis Medical, medical aid schemes in South Africa may impose certain waiting periods on new members and their dependants when joining.
Typically, waiting periods depend on the amount of time an applicant has been a member of a South African medical scheme at the time of joining a new scheme and the new scheme will probably assess the health risk profile of the applicant.
According to the Medical Schemes Act, medical aid schemes impose a three-month general waiting period. As well as a 12 months condition specific waiting period for any pre-existing medical condition.
These waiting periods protect medical schemes from people that only join when they require medical attention.
All info was correct at time of publishing