How to Decode Your Medical Aid Scheme Ts and Cs

Introduction to Terms and Conditions of Medical Schemes.

Medical aid schemes often have to make changes to the plans and benefits they offer. This is to overcome the effect of rising costs. For this reason it is essential to review your plan annually.

This warning comes from the CEO of the Independent Community Pharmacy Association (ICPA), Mr Mark Payne, who says it is the only way to ensure that medical aid plans continue to serve member needs.

General Terms and Conditions

According to the ICPA, there are important issues to consider when choosing a new medical aid scheme. Or even when reviewing one you already have. Thse are:

  • Who administrates the scheme?
  • How much cover do you get for medical costs?
  • What are the plan exclusions?
  • Do members have to make co-payments?
  • Are service provider networks specified?
  • Whether chronic medication cover is on offer

Terms and ConditionsPayne points out that members of all medical aid schemes are entitled to have copies of the scheme’s registered rules, annual reports, and financial statements. The rules are particularly important. These specify benefit options, contributions, and the rights and obligations of the members.

He warns that it is essential to read all disclaimers as cover is usually subject to “available benefits”. Furthermore, the authorisation letter of medical aid schemes is not proof that it will pay for all procedures in full.


Find out who administrates the medical scheme and whether they have a good track record in terms of processing claims and paying out. This information is available from the Council for Medical Schemes, or from a good broker.

Terms and Conditions – Cover

Different schemes offer different cover, and even this can change. The most common coverage is 100 to 300 percent of the medical scheme’s own rate, created using the National Health Reference Price List as a guide. For this reason it is vital to negotiate (or at least be sure of) rates that all health care professionals will charge before treatment begins. Some doctors and specialists charge medical scheme rates (MSR), but if they charge more than these, patients are usually liable for the difference between the MSR and what appears on the bill – particularly if it was not an emergency procedure.

Even hospital plans generally only cover legally Prescribed Minimum Benefits (PMB).

Gap cover is an option to cover these shortfalls.

Terms and Conditions – Exclusions

Most medical aid schemes have some sort of exclusions, and these can change annually. For this reason ICPA advises all members of medical schemes to check the exclusions pertaining to their plans.

Terms and Conditions – Co-payments

There is no hard and fast rule when it comes to co-payments. It depends entirely on the medical scheme’s policy, what procedure, and whether this take place in a hospital or not.

Terms and Conditions – Service Networks

Preferred provider or service provider networks are very common in the medical aid industry, largely to minimise or at least “contain” rising costs. If the plan specifies a network, either for a hospital and/or services or medicines, this generally removes all personal choice. Members might be able to choose the health care professional or service provider, but then they either have to pay the difference in cost, or will have to pay a penalty co-payment fee.

ICPA recommends that members check which pharmacies have contracts with their medical aid scheme. The Association also advises members across the board to choose medical and health care professionals who are willing to advise on affordable care and alternative treatments.

Terms and Conditions – Chronic Medication

Chronic medication options are often limited to designated service providers, either in total, or once the chronic benefit limitation has been reached.

Payne doesn’t believe it makes any sense to force patients to to switch from their usual community pharmacy to “a non-descript courier pharmacy” just because they reach the chronic benefit limit.

He warns patients which chronic conditions to make sure they have cover for their specific condition in the plan they choose, and that it is in fact a chronic condition. It is also important to check that the medication prescribed is covered too. If the medication you normally take is not covered, you might have to change medication, pay a penalty, or have to chip in extra for the meds previously prescribed.


Ultimately, benefits should be used to maintain your health and manage any chronic condition, says Payne.



All info was correct at time of publishing