Medical Insurance Glossary


Acute Condition
An acute condition is sudden in onset, of short duration, and requires urgent care, e.g., appendicitis and tonsillitis.

Annual Limit
Medical Schemes and Medical Insurance providers can impose a yearly limit on certain medical treatments or procedures.

A general term referring to any service provided by a medical practitioner like pathology tests or surgical procedures, or supplies like medication or medical equipment, covered by your Medical Aid or Medical Insurance policy.

Chronic Condition
A chronic condition refers to a permanent, recurring or long-lasting illness, e.g., hypertension and diabetes.

A request for compensation for medical services rendered in terms of the Medical Insurance policy.

A portion of the bill for which the member/policyholder is responsible. A co-payment typically applies when the scheme/policy only covers treatment at a certain percentage and the provider charges above that percentage. This means that the Medical Aid or Medical Insurance provider will pay a certain amount (as specified in the plan/policy) while the member/policyholder is responsible for the rest.

Council for Medical Schemes
The Council for Medical Schemes (CMS) is a statutory body established by the Medical Schemes Act (131 of 1998) to regulate the medical schemes industry in a fair and transparent manner.

Day-to-Day Benefits
Day-to-day benefits refer to all the medical expenses you might incur in your everyday life that does not require hospitalisation. Day-to-day benefits can include doctor’s visits, medication for colds and flu, or trips to the dentist.

Designated Service Provider (DSP)
A Designated Service Provider or DSP is a specific service provider like a hospital, doctor or pharmacy that the Medical Aid or Medical Insurance provider has an agreement with. Members/policyholders will receive preferential rates when they visit a DSP, which means that they can obtain treatment at a lower cost.

A serious, unexpected, and life-threatening situation requiring immediate medical action.

Financial Services Board
The Financial Services Board (FSB) is an independent body that oversees the non-banking financial services industry, which includes short- and long-term insurance, funeral insurance, schemes, and financial advisors and brokers. The FSB ensures that consumers are treated fairly by financial services providers.

Funeral Cover
A form of insurance in which a lump sum is paid out should you pass away. Funeral Cover helps reduce the financial burden that the cost of a funeral may present.

An institution providing medical treatment and nursing care for sick or injured people.

Hospital Confinement
Be admitted to hospital due to illness, disability, or before, during and after giving birth.

Insured Person
This refers to the person that is covered under the Medical Insurance policy. The insured person can also include an eligible spouse of a principal insured person or an eligible child of a principal insured person. Essentially, the insured person refers to the person that will benefit from the Medical Insurance policy.

Medical Aid / Medical Scheme
A Medical Scheme provides in-hospital cover and can also provide cover for day-to-day medical expenses like doctor’s visits and medication for colds and flu. A Medical Scheme is registered by the Registrar of Medical Schemes in terms of the Medical Schemes Act No. 131 of 1998.

Medical Insurance
Medical Insurance is an insurance product that provides cover for hospitalisation. A set amount is paid out for each day spent in hospital.

Medical Practitioner
A legally qualified medical practitioner registered with the Health Professions Council of South Africa (HPCSA).

Medical Schemes Act 
The Medical Schemes Act, 1998 (Act No. 131 of 1998) consolidates the laws relating to registered medical schemes; to provide for the establishment of the Council for Medical Schemes as a juristic person; to make provision for the registration and control of certain activities of medical schemes; and to protect the interests of members of medical schemes.

Monthly Contributions
The instalment paid to the chosen Medical Insurance provider each month to enjoy the benefits of being covered by the Medical Insurance policy.

Personal Accident and Disability Cover
Provides cover to protect yourself or your loved ones financially if you become disabled through injury or illness.

The monthly instalment paid to the chosen Medical Insurance provider to remain covered.

Prescribed Minimum Benefits (PMBs)
Prescribed Minimum Benefits or PMBs refers to a list of approximately 270 medical conditions that medical schemes need to cover in full, regardless of the particular plan you’re on. The law does not require Medical Insurance providers to include cover for PMBs.

Short-Term Insurance Act
The Short-Term Insurance Act, 1998 (Act No. 53 of 1998) provides for the registration of short-term insurers; for the control of certain activities of short-term insurers and intermediaries; and for matters connected therewith.

A table of the fixed charges made by a service provider like a doctor, specialist or hospital.

Medical care provided by a medical practitioner for an illness or injury.

Waiting Period
A period of time (usually 3 or 12 months) in which you cannot claim for certain benefits. A general waiting period (usually 3 months) can apply in which you cannot claim any benefits or a 12-month condition-specific waiting period can apply in which you cannot claim benefits for a pre-existing medical condition. 

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