Medical emergencies can pop up when you least expect them, and the costs for treatments, hospital stays, and meds can pile up fast. That’s where health insurance comes in handy – it acts like a safety net, helping to cover the gap between the care you need and what you can afford.
While opting for affordability, Thembile Hlophe from Durban says the medical insurance she applied for also came with frustrations.
“I took out medical insurance for my sister, who was not on the medical aid because it was expensive getting her one since she is an adult. I cancelled it within 3-4 months after using it and put her back on my medical aid because of the inconvenience it had.
“There were too many Ts & Cs that were not communicated clearly when I signed up. I had to pay GPs upfront, then I would have to upload an invoice and a receipt on their app before they could process a refund. What a headache!”
She says the real shock came when she discovered the limitations of the insurance policy when it came to hospital admissions. “When it comes to admission, you could only be admitted for breathing difficulty-related issues.
Affordable healthcare option
“In terms of affordability, I would say yes, it’s fair when you look only at premiums. But the service and the runaround you get before your claim gets approved are not worth it. But maybe I was with the wrong insurer; I don’t know how others feel. But I would never move back to insurance,” says Hlophe.
For Mzamo Nkosi from Johannesburg, medical insurance has proven to be valuable over the past four years. Despite some challenges, he believes it offers real value, especially when faced with the unpredictable costs of healthcare in South Africa.
“I think it’s value for money. I need to be well taken care of whenever I’m hospitalised and not worry about hospital bills. Medical insurance gives me a piece of mind. I can be covered for expensive surgery and CT and MRI scans for proper diagnosis when necessary. Those scans can be very expensive.”
Despite being a beneficiary of a good policy, Nkosi believes that medical insurance should be more accessible to all South Africans, particularly those earning minimum wage.
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What is covered and what is not
According to Cape Town-based medical scheme advisor Aaltje Gouws, there are several key components that medical insurance typically covers, which include:
- Visits to healthcare providers: This includes appointments with your primary physician, specialists, and other medical providers – normally only at specific designated/contracted providers.
- Hospital services: Coverage for services received at a hospital, such as emergency care, surgeries, outpatient care, procedures, or overnight stays.
- Prescription drugs: Most plans offer prescription drug coverage, but the specific medications covered can vary by insurer.
- Preventive services: Many plans cover preventive health services at no extra cost, including screenings and vaccinations.
Gouws also explains that medical insurance plans can be customized. “One can apply for standalone benefits or a combination. For example, you might pay a premium for visits to healthcare providers and add on emergency hospitalisation coverage for an additional premium.
When comparing medical insurance to medical aid, Gouws emphasises several major distinctions to keep in mind, such as:
- Medical aid in-hospital benefits are unlimited versus medical insurance, which will provide a specific amount.
- Medical aid pays the hospitals directly, whereas medical insurance will pay the policyholder; therefore, hospitals do not accept insurance products as a quarantine for payment, and policyholders must pay first and then claim back from their insurance product.
- Medical aid is regulated by the Medical Schemes Act, and medical insurance products by the Long-Term Insurance Act.
- Medical aid will provide necessary benefits until death; medical insurance can terminate your policy at any time if a risk.
Medical insurance is often seen as a more affordable option for those who cannot bear the high costs of medical aid premiums. “You budget for a monthly premium and know that, depending on the coverage you have, your policy can pay for most medical expenses. It provides peace of mind, especially for those who can’t afford a medical aid premium,” Gouws says.
“It’s important to note waiting periods for medical insurance, and the stated amount must at least cover 80% of costs (otherwise you pay a monthly premium and still have a lot to pay out of your own pocket); and at what age the policy will be terminated.”
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