Option available for consumers
Medical insurance and scheme differ
There is an option of a medical insurance.
The CEO of medical aid scheme Profmed, Craig Comrie, says that medical aid and medical insurance may seem like the same thing, however, the truth is that they are two different products.
“It is worth mentioning that while medical aid is more expensive than medical insurance, there are more to these products than just the price point,” says Comrie, noting that consumers must consider what’s best for their families.
What is the difference between a scheme and an insurance?
Comrie says on a scheme, which should be registered with Council for Medical Schemes (CMS), even the lowest cover offers a reasonably comprehensive set of benefits known as prescribed minimum benefits.
According to CMS, these are a set of defined benefits to ensure that all medical scheme members have access to certain minimum yet broad-based set of health services, regardless of the benefit option selected.
These benefits aim to maintain a lowest level of acceptable cover to medical scheme members. Also, the benefits cannot be restricted in terms of funding and, in general, do not require any co-payments from members.
Medical insurance sits on the other end of the value scale, paying a set amount for your stay in hospital, usually restricted to a maximum of between R150 000 or R300 000, often not enough considering the high costs of medical care.
Comrie says that medical insurance or hospital plans, as we all know them, are not necessarily the cheapest option. With the current state of the economy, many South Africans have been forced to downgrade their medical aid option, but even that may not be the most economical choice.
“You have to know your health status before you just downgrade your health cover. Do you have a chronic condition? Do you require dental treatment, or need regular check-ups and tests for a particular illness?
Consider your health status before opting for a downgrade
“These are all items that are likely not going to be covered in your hospital plan and will come straight out of your pocket,” says Comrie.
He notes that terms and conditions apply when taking a hospital plan. These include:
• Medical insurance can be taken out as a stand-alone product when your medical aid savings account/day-today benefit has run out.
• Medical insurance pays you, not the provider. This means you will need to settle your accounts.
• It pays out set amounts selected when taking out the cover (e.g per hospital visit or procedure with overall annual or per event limits).
• It usually offers limited cover for day-to-day medical expenses such as GP visits.
• It does not have cover for prescribed minimum benefits.