Health - FAQ's For Medical Aid

In laymen's terms, the purpose of a medical aid is to ensure that you are able to pay for treatment received from either a GP or specialist, or while in hospital. It is very important to "insure" your health. Accidents can happen and you and your family's health are unpredictable.

Yes. Medical aids used to be able to reject applicants based on their age or health but it is no longer legal to do so. Cover can be excluded for a period of time e.g. a pregnancy may not be covered if you are already pregnant when you apply.

In some cases, medical aids are entitled to impose a 3 month general waiting period, during which no claims will be paid, and / or a 12 month exclusion for any pre-existing medical conditions.

No, it is legislated that you may only belong to one medical aid scheme.

Employers do not have to subsidise employee's medical aid contributions but some employers choose to do so.

Yes, your membership can be terminated if your contributions are not paid. If you are on a restricted scheme (only available to a specific group of people or employers) your membership will also be terminated if you are resign, or made redundant or retrenched.

You are covered for treatment that is carried out up to and including the last day of your notice period.

Claims must be submitted to the scheme within 4 months of the treatment date.

Your dependants will need to notify the scheme and discuss the continuation of membership.

In a rapidly changing environment, ongoing evaluation of your medical scheme has become vital to ensure optimum benefits are available and that you are covered for foreseen and unforeseen medical conditions and emergencies.

Review your own personal needs and basic requirements. Are you still single or have you got married? Do you have children? Have you been diagnosed with a new chronic condition?

The Medical Schemes Act makes provision for schemes to apply a late joiner penalty to members over the age of 35. Depending on the number of years that you have not belonged to a registered South African medical scheme since the age of 21, the late joiner penalty is calculated as a percentage of your monthly contribution and will be added to your monthly contribution.

A medical savings account is a pool of the member's own money set aside from the contribution for payment of day-to-day medical expenses (anything that happens outside of a hospital). Any portion that is not used in the year carries forward to the following year and is paid out upon termination of membership.

In the case of a medical aid with a medical savings account, your out of hospital expenses are limited to the amount of medical savings you contribute. On a capitation plan, your out of hospital expenses are limited to a clearly defined number of visits or monetary amount per benefit.

These plans make use of a network of hospitals, doctors and/or dentists that the member must use in order to be covered. This keeps the costs for the medical aid schemes down, which allows the contributions to be cheaper.

A comprehensive plan has a high level of hospital cover, day-to-day benefits and chronic medication benefits. A threshold benefit is usually also included which provides insurance cover if your day to day medical expenses exceed a certain amount.

A co-payment is a portion of the cost of a procedure for which the member is responsible.

A group of medical service providers specified in the scheme rules from whom services must be obtained to enjoy appropriate treatment and lower or no co-payments.

This is a list of 270 treatments for which all medical aid schemes in South Africa have to provide cover in terms of the Medical Schemes Act. It also includes the following 26 chronic diseases:

Addison's Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, Chronic Renal Disease, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Crohn's Disease, Diabetes Insipidus, Diabetes Mellitus Type 1 & 2, Cardiac Dysrythmias, Epilepsy, Glaucoma, Haemophilia, HIV / AIDS, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson's Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus and Ulcerative Colitis

No, not unless it is a restricted scheme and the member is not entitled to join that particular scheme. In the event of non-disclosure, the scheme may request immediate termination of membership.

This process varies depending on the scheme that the member is applying to(It is best to discuss this information with our Medical aid specialists).

In order for members to qualify as dependants, they need to be the member's spouse, child or financially dependent on the main member (and be able to provide proof if necessary).

Most schemes charge adult rates for children from the age of 21 even if they are full time students, but this varies according to scheme.

No, the Act prohibits the payment of bonuses, rebates or refunding of any portion of contributions other than in respect of savings accounts upon resignation from the scheme.

In most instances, your provider will submit claims directly to the scheme and provide you with a copy for your records. Where providers do not submit to the scheme, it will remain your responsibility. Ultimately, each and every claim remains the responsibility of the member.

For certain procedures, or if you or any of your dependants are admitted to hospital, pre-authorisation must be obtained from the scheme.

In order for a membership to be terminated, the member needs to provide the scheme with written notice. It is important for the member to find out exactly what the schemes notice period is. Most schemes require one calendar month's notice, while some require up to 3 months.