Medical aid jargon can be pretty confusing to say the least…
In today's world, many of the most commonly used terms have been reduced to acronyms and other jargon. There is industry-specific jargon which can be confusing for the average citizen to fully understand, particularly when it comes to medical aid.
Having an understanding of the terminology will help you to better understand what each of them means. Let’s take a look at some of the more common ones.
This refers to the main member of the medical aid scheme, either a sole member or, in the case of family members, registered one or more dependants. The principal member pays the larger contribution to the scheme than the dependants do. The other members and their dependents are referred to as beneficiaries.
In some cases, the medical aid scheme imposes a late joiner penalty on persons who join the medical aid scheme after the age of 35 years. This can apply to those persons who have never been an active medical aid member or those who have not belonged to a medical aid scheme for a specific amount of time.
Medical aids are allowed to impose a waiting period on new members, this is to protect other members of the medical aid scheme by ensuring that new members cannot make large claims against the scheme on joining and then canceling their membership.
These are predefined benefits that all medical aid scheme members are entitled to regardless of the level of benefits to which they have subscribed.
There are 270 recognized PMBs, including all emergency (life-threatening) conditions and 27 chronic conditions.
This refers to the doctor, pharmacist or hospital that has been contracted by your medical aid scheme as the first choice when you need to be diagnosed or treated. Medical aid schemes agree to pay the healthcare providers a specific rate for the services they provide.
This is a portion of the procedure or treatment for which the member is responsible. The normally apply when a member elects to use a non-DSP as described above. They can also apply to specific in-hospital procedures like scan or scopes as well as specialised dentistry
Provides basic but important medical aid cover, the hospital plan covers a range of treatments and procedures whenever you are admitted to the hospital.
Generic medicines contain exactly the same ingredients as those with high profile branding. The same company or another medical company manufactures these medications when the patent on the branded product expires, resulting in the generic medication being cheaper.
Some medical aid benefits are given on a calendar year basis, this means that there is an annual limit on the benefit. If you join your medical aid scheme after the 1st of January, your benefits will be calculated pro rata. This means you will be given years medical benefits in advance.
Some medical conditions and procedures may be excluded from your medical aid scheme. An example of this would be cosmetic surgery
There are plenty more to come to grips with, but at least this list will give you some idea of the terminology used in the medical aid industry