Do you need medical aid or health insurance? What is the difference between them and how are they the same? If these are questions you want to know the answer to then this is the blog for you. Which of these options is right for you depends on what you need, what you can afford and in some cases what you qualify for. On the one hand you might find yourself with too little cover and end up paying for a lot out of pocket on the other you may be paying for cover you don’t use. One thing is certain though, if you are informed you will be able to make the best decision, so let’s dive in.
What is Medical Aid?
Medical aid South Africa is defined as a regulated program whereby its members have access to an extensive range of healthcare services, paying a certain amount monthly to the medical scheme. As a result of paying this, the members receive benefits like:
- Hospitalisation and certain out-of-hospital treatments.
- Day-to-day medical expenses like visits to a doctor, medication, and specialist consultations (depending on the plan).
- Prescribed Minimum Benefits (PMBs) which are benefits for core therapy on certain conditions and emergencies.
Medical aids work on a pooled basis where all members’ contributions are pooled and works to cover medical expenses for the most needy. Hence, ensuring some baseline security and peace of mind.
Requirements for Joining a Medical Aid
While medical aids are widely accessible, there are specific requirements to consider when applying:
- Age Limits: Some medical aid options cater to individuals of all ages, but medical aids may have tailored plans for young adults, families, or retirees. Children can remain on their parents’ plans as dependents until a certain age, often up to 21 or 24 if they are studying.
- Medical Underwriting: Medical aids may require new members to undergo a medical underwriting process. This could include completing a detailed medical history questionnaire.
- Waiting Periods: Members are often subject to general waiting periods (up to three months) or condition-specific waiting periods (up to 12 months for pre-existing conditions) before they can claim benefits.
- Medical Exams and Tests: While not always required, some medical aids may request medical exams or tests, especially for applicants with pre-existing conditions.
- Affordability Requirements: Members need to meet the monthly premium payments based on the plan they choose, with costs varying by the level of coverage.
- Compliance with Medical Aid Rules: Members are expected to abide by the rules of their chosen medical aid, including pre-authorisations for certain treatments and hospital admissions.
What is Health Insurance?
As opposed to medical aid, health insurance South Africa generally offers specified compensation for certain medical incidents at a lower cost. Additionally, health insurance often does not require a medical exam like medical aid does and it can be purchased in conjunction with a medical aid as a top-up to cover bolster specific health issues or to cover additional expenses. Unlike medical aid South Africa, it doesn’t take care of – the majority of the healthcare expenses, but it offers the following benefits:
- Fixed cash payments for events such as hospitalisation, surgery, or critical illnesses.
- Limited coverage of day-to-day medical expenses.
- Free to use cash however you like, whether it be for medical bills or some other financial needs.
Health insurance South Africa is usually seen as the quick simple coverage without the high premium costs of medical aid South Africa.
Which One is Right for You?
When choosing between medical aid vs health insurance, the individual would need to make this decision based on their healthcare needs and budget:
- Medical aid South Africa works best for families, those with chronic conditions, or those who have to seek medical care frequent times, since they have comprehensive coverage and PMBs.
- If you’re young, healthy, and looking for an affordable way to protect yourself against major medical events, health insurance South Africa could suffice.
Still not sure?
If you are unsure which option is best for you contact us and one of our expert advisors will give you free and impartial guidance.
Conclusion
Remember that there are merits to both medical aid and health insurance as part of South Africa’s healthcare system. Compare your needs with what fits your budget, ensuring the best balance between your health and your finances.