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Medical scheme speed bumps

Sep 10 2014 07:17
*Susan Erasmus

Cape Town - You’re not worried about medical costs – you pay your scheme contribution every month. Case closed? Unfortunately not. While many medical schemes come to the party when you need them most, medical scheme members can get a grim surprise when they least need it.

This is why is it absolutely essential to read the small print on the benefits for the particular option you have chosen. There are huge differences in benefits offered from scheme to scheme and from option to option within those schemes.

You could find yourself having to make a co-payment of thousands when you least expected it.

One of the reasons why it is so important to know these details is that your medical needs could change. You could develop a new condition, or an old health issue could be resolved.

You get what you pay for: never is that more true than when it comes to medical schemes. It’s a bit like your home insurance – you don’t want to find out you’re not covered for your tree falling on to the neighbour’s roof when it has already happened. If you haven’t done so yet, make it a priority today to go and read the small print describing your benefits.

While some of these limits may seem unfair, it must be remembered that if a scheme were to pay all costs for all of its members, it would go under very quickly. It has to limit its healthcare expenditure for the benefit of all its members. It’s just not very pleasant when you are the one having to fork out unexpectedly.

Here are some speed bumps medical scheme members can encounter:

Cancer treatment

Many schemes have a rand limit on approved oncology treatment within a 12-month period. It could be anything, but the ceiling is usually between R250 000 and R400 000. After this, you could be required to make a 20% co-payment, or pay for it yourself, which could amount to a substantial amount of money. You can be required to go to a network specialist specified by the scheme. Find out if you need to be hospitalised before your scheme will pay for this treatment.

In-house agreed tariff

Every scheme has tariffs, according to which they pay doctors and specialists. In other words, if you choose to go to a doctor that charges three times what the scheme’s tariffs are, you will be footing two-thirds of the bill. Don’t be fooled by the words ‘100%’ in the benefit tables – it is followed by the very important phrase ‘of the agreed tariffs’. The same goes for in-hospital specialists and hospitals not part of a specific network.

Medical savings account
The medical savings sccount (MSA) is usually 15% to 20% of your total contributions. It is put into a savings account, from which items such as GP visits and acute medication will be paid. Check to see what benefits are paid from the savings account. It is all added together to reach the total. So a visit to the dentist and a bout of bronchitis could actually wipe out your MSA for the year.

Then you go into a self-payment gap (which is self-explanatory), after which above threshold benefits can kick in. Check what, if any, limits there are on these. This is only for people on full medical schemes with day-to-day cover. Hospital plans do not have MSAs.

Remember, this money is yours. What you don’t use gets carried over to the next year, and if you leave the scheme, unused funds from the MSA will be paid out to you.


In many countries medical schemes do not cover dentistry at all. People have to take out a separate plan to cover dental work. If your dentistry benefits are paid from your MSA, they don’t go very far. Also remember that schemes will not pay for anything they see as purely cosmetic – and they are conservative in this regard. If you need several teeth crowned, best you start saving.

MRI and CT scans

These can cost thousands. Check to see whether your plan will only pay if you are hospitalised, or whether they will only pay for a certain number of scans per calendar year. Some options cap this benefit on a rand value, such as R2 750. This might not cover the cost.

Chronic medicines

Schemes and hospital plans have to pay for the medication for 27 chronic conditions. Some schemes have medicine formularies, according to which they either cap a rand value on what they will pay for a certain condition, or prescribe which drugs (often generics) they will fund. If you want to take specific brand medicines not listed, you will have to pay the difference yourself.

Network hospitals and specialists

Generally if you use hospitals and specialists on the network of your scheme, you should have no co-payments. But not every scheme has a network. Contact your scheme before you go for treatment or before you are hospitalised, to make sure that you are not landed with a huge unexpected bill. Use the network hospitals and specialists wherever you can.

Home nursing and frail care

Few options on medical schemes have benefits for this. If they do, it is usually limited for a specified time, or a specified amount. Don’t assume these services will be paid for. Most schemes would go under if they had to fund unlimited frail care, so it is understandable.

Elected Caesareans

More and more women are choosing to have Caesarean sections rather than natural births. But it costs more, and schemes are within their rights not to pay for elective Caesareans. It’s a different matter if it is a medical emergency, or there is no choice in the matter, but don’t assume your scheme will foot the bill if it is your personal choice.

 - Fin24

*Susan Erasmus is a freelance writer.

References: Council for Medical Schemes; Discovery Health; Selfmed; Fedhealth;

health insurance  |  medical aid  |  money


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