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.
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.
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.
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.
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.