Shop around for best medical cover: According to Stats SA survey, only 17% of South Africans have medical aid, the reason being affordability.

The premiums can be a daunting monthly expense which many may not deem necessary, but medical aid can literally save both your and your loved ones’ lives.

CHOOSE WISELY: It is important to compare costs and benefits from several providers in order to get the best deal. Picture: ISTOCK

According to last year’s Statistics South Africa (Stats SA) General Household Survey results, only 9.5 million South Africans belong to a medical aid scheme.

Broken down, that translates to only 17% of the South African population.

Based on the Stats SA report, there are various public health facilities which do service those without medical aid, although half of the country’s health professionals admitted to only servicing those South Africans with medical cover.

With hundreds of different providers and just as many plans available, how does one go about choosing a plan which covers healthcare needs but also falls in line with affordability?

Jill Larkan, head of healthcare consulting at GTC, said the most important considerations to take into account include the level of in-hospital cover which the medical aid provides, coupled with the premium you can afford and whether or not you would like your medical aid to cover any out-of-hospital expenses such as doctors and pharmacy expenses.

According to Larkan, medical aids come with different levels of in-hospital cover, some from as low as 80% with some going as high as 300%. (Most specialists charge more than 100% of the tariff.)

With regards to out-of-hospital cover, Larkan said there is a much smaller risk element for the member to bear and these expenses rarely run into hundreds of thousands of rands, as a hospital stay might.

“Affordability is always a very big factor, but it also boils down to how high you value access to private healthcare for yourself and your family and if you are willing to make other sacrifices in your monthly budget to invest in health cover,” advised Karin Haggard, executive consultant at Optivest Health Solutions.

“You should ask yourself how much risk regarding your own and your dependants’ health you would like to insure.

“If you are still young and healthy, how important is it for you to have cover should you or a loved one be injured in an accident or are diagnosed out of the blue with a critical illness?

“An additional consideration factor is to also have extra budget for a medical aid option that offers cover for day-to-day benefits such as dentist and GP visits.”

To try and minimise monthly medical aid costs, chief executive of online insurance and financial comparison website Hippo John October advised consumers to:

  • Compare costs and the benefits which will suit your individual needs from at least three different providers to ensure that you are not paying too much for the same cover;
  •  Carefully consider your health requirements for the next 12 months to ensure you will be adequately covered by your medical aid;
  •  Should you be at a stage where your children are financially independent and need to be removed from your medical aid, consider re-evaluating your overall cover as you may no longer need certain benefits; and
  •  Manage your medical savings by visiting doctors with lower rates and comparing the cost of medication at the practitioner’s pharmacy with that of a local pharmacy outlet to determine the lowest cost.

Larkan warned of many pitfalls consumers regularly fall into when choosing their ideal cover.

“People often ‘understand’ that they are on a 100% medical aid, without understanding that this does not mean that they are covered for 100% of the costs, but 100% of the medical aid rate … which is usually substantially lower than 100% of the costs, resulting in members being angry at not being aware, and being left with having to pay out large sums of money to cover the difference.

“People are also often not aware that their medical aid has an obligation to cover their chronic medication as well as a certain number of visits and tests relating to their chronic ailment.

“This must be covered from the medical aid’s risk account and not the members’ savings account. There is a specific list of conditions accepted under this prescribed minimum benefit allocation which is available from each medical aid.

“People often mistake cheap medical insurance for a comprehensive medical aid. This may be because of fanciful marketing done by the medical insurance company which made the member believe that they were joining a medical aid, or simply because of ignorance.

“We often believe what we want to believe without doing the proper research,” Larkan said, adding that the professional financial advisers who assist consumers to take out their medical aid cover are available to provide any advice.

“Members are not aware that part of their monthly premium is being paid to a professional financial adviser, usually the person who sold them the medical aid in the first place, and that this person is available to them on an ongoing basis to provide them with advice regarding their medical aid, options, and year-end changes, to name only a few of the services provided to members by professional healthcare consultants.”

Before choosing cover, Haggard stressed the difference between medical aid cover and hospital insurance, which may sound alike but are completely different.

She said: “There is a very big difference between hospital insurance and medical aid. Hospital insurance is a short-term insurance product with a focus on primary health and covers health events at fixed or very tightly defined amounts and it is paid to the client directly and not to the medical service provider.

“Medical aid is governed by the Council for Medical Schemes and the Medical Schemes Act and it’s a non-profit organisation which must, according to law, cover a list of prescribed minimum benefits which are the diagnosis, treatment and care linked to a list of 270 health conditions and 25 chronic conditions.

“The legislated prescribed minimum benefits ensure that a medical scheme cannot apply a rand limit per day for in-hospital treatment of a life-threatening or life-sustaining medical condition.

“Hospital insurance products do not offer this guaranteed protection and as a result clients with these type of products are still exposed to major financial risk.

“Consumers should be aware of this and ensure they get the right guidance when considering taking up any of these products.”

As October is the month when consumers can start reviewing their medical aid plans before renewal, now is the time to shop around for the best possible rates.

“There are various factors such as unemployment, economic climate and lack of affordability that impact whether someone can afford membership to a medical scheme or not. But in many cases, people simply have no choice but to belong to a medical aid scheme.

“Many have to take compulsory schemes through their employers or have the need for specific medical care or treatment that they cannot afford as an out-of-pocket expense,” he concluded. — zisandan@dispatch.co.za

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