How to Decode Your Medical Aid Scheme Ts and Cs


Medical aid schemes are often forced to make changes to the plans and benefits they offer 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.

According to the ICPA, important issues to consider when choosing a new medical aid scheme or reviewing one you already have are:

  • Who administrates the scheme
  • How much of medical costs are covered
  • What is excluded from the plan
  • Whether co-payments are required from members
  • Whether service provider networks are specified
  • What chronic medication cover is offered

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 as these specify benefit options, contributions, and the rights and obligations of members of the scheme.

He warns that it is essential to read all disclaimers as cover is usually subject to “available benefits”. Furthermore, the usual authorisation letter provided by medical aid schemes does not provide proof that procedures will be fully paid for.


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.


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 will be charged by all health care professionals before treatment is administered. 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 is charged – particularly if it was not an emergency procedure.

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

Gap cover is an option that may be used to pay for these shortfalls.


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 what exclusions are included in their plan.


There is no hard and fast rule when it comes to co-payments members are required to make. It depends entirely on the medical scheme’s policy, what procedure is carried out, and whether this is done in a hospital or not.

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 may be able to stick with the health care professional or service provider of their choice, but then they either have to pay the difference in cost, or are charged a penalty co-payment fee.

ICPA recommends that members check which pharmacies are contracted to 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.

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 for patients to be forced to switch from their usual community pharmacy to “a non-descript courier pharmacy” just because they have reached the chronic benefit limit.

He warns patients which chronic conditions to make sure their specific condition is covered in the plan they choose, and that it is in fact regarded as 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.