As with everything else in life, with medical aid what you pay for is what you get. And especially in an area as complicated as the health industry, it is often a case of caveat emptor – let the buyer beware. Here are some factors to consider before opting for a so-called cheap medical aid scheme.

So-called 100% cover

To the uninitiated 100% cover sounds like all the cover you will ever need. However, with medical aid schemes this is not the case. Every year the Department of Health publishes the National Health Reference Price List (NHRPL), compiled by the Council for Medical Schemes. This list prescribes the rates and tariffs for specific services and procedures. However, only 45% of health care practitioners charge NHRPL rates, while the rest charge anywhere up to 300% of these rates. Private hospitals typically also charge more than NHRPL rates. Therefore most comprehensive medical schemes speak of 300% cover for specialist consultations and hospital procedures. If your medical aid does not provide this extra cover, you will be liable for anything that your doctors charges over and above the NHRPL rate. For a single consultation this might not be excessive, but for something like a CT scan, this can easily cost you an additional R5000.

Limits may apply

Be sure to enquire what the day-to-day (out-of-hospital) limits of a medical scheme are. If these limits are very low, you could find that two or three consultations with a specialist have exhausted your day-to-day benefits. Certain medical schemes also limit hospital payouts to a certain amount per family per year. This could land you in a serious predicament if more than one family member were to require hospitalisation in a given year.

Exclusions to your cover

As a new member of a medical scheme, there are obviously waiting periods that are applicable, but make sure that you know if there are conditions which are excluded from cover for a limited period. Some medical schemes will enforce no waiting period, some will enforce a general waiting period of up to three months, and some will enforce a condition-specific waiting period of up to twelve months.

You may also find that conditions owing to obesity, infertility treatments, treatments done for cosmetic reasons, experimental procedures, etc are all classed as exclusions by your medical aid.

Exercise caution

The Council for Medical Schemes warns members to:

  • Make sure you know and understand the rules of your scheme.
  • Read all correspondence from your scheme.
  • Study your benefits guide.
  • Familiarise yourself with the terms and conditions of the benefit option that you have chosen.
  • Make sure your contributions are paid in full and on time every month.

Lodging a complaint

Your first step when you feel that you have been treated unfairly is to lodge a complaint with your medical scheme, but if you are not satisfied with the outcome, you can complain to the Registrar of Medical Schemes. You can write to or 0861 123 267.

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