Things your Medical Aid won’t pay for.
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How to really protect yourself from medical aid shortfalls.
Medical aid is your first step in being able to afford private healthcare in South Africa.
But, there are certain costs that medical aid schemes may not cover, leaving you exposed to the threat of unexpected expenses.
Here are some of them with ideas on how to reduce the threat they have for you.
1. In-Hospital shortfalls
Most medical aids have limits for the in-hospital costs that they cover (they call these sub limits), which vary depending on what plan you are on.
Private specialists charge more than the scheme's rate and you are responsible for that shortfall.
You may be able to cover minor procedures, but serious procedures like premature birth or surgeries can cost thousands of rands.
In addition, procedure co-payments are increasingly being levied by medical aids.
The Answer to this is Gap Cover
This is an insurance that helps you pay the gap between what your medical aid pays and what healthcare providers charge.
It only pays in-hospital costs shortfalls, but we do have a plan that also includes certain out-patient procedures.
2. 
Day-to-Day medical costs and savings plan shortfalls
Most medical aids include a medical savings account for everyday expenses like GP visits, dentistry, and medication.
Part of your premium pays this fund, and these monies are used to pay for day-to-day expenses.
But, once the savings are spent, especially on lower-cost/benefit plans, you must self-pay those additional costs.
Long-term treatments like physiotherapy can be expensive.
The Answer to this is to have an accessible emergency fund in a bank account or unit trust investment that you can use at short notice.
You need to start saving now and building a fund that will help you meet those unexpected costs.
If you need frequent medical services, consider a unit trust, an excellent, easy-to-access investment that will grow in value if unused, benefiting you in many ways.
Prescribed Minimum Benefits (PMBs) are conditions and treatments medical aids must pay for.
Ensure that if you have any PMB conditions, you register them with your medical aid's treatment plan.
More expensive plans have Above Threshold Benefits.
These are available once your savings are spent, and your claims have added up to a pre-determined amount.
Your medical aid then provides additional benefits.
Always submit claims, even if you self-fund them, as they add up to this threshold amount.
Use Day-to-Day benefits that not paid from your savings.
Certain screenings and tests may be covered as part of a wellness benefit your medical aid offers.
We can help you find out if you have access to these treatments.
We can help you find out if you have access to these treatments.
Consider upgrading to a plan with a higher savings fund if you constantly spend your medical aid funds.
Use your medical aid preventative care plan, as regular check-ups and screenings are often paid for by medical aids and this will help reduce potential future medical costs.
3. Internal and External Prosthetics and Assistance Devices
Medical aids sometimes do not cover (or cover only part of the costs) for prosthetics.
Advanced prosthetics, such as joint replacements, and disability-related equipment, like wheelchairs, may not be fully covered, leaving you to find alternative funds.
Make sure you know your benefits, especially if you are likely to need them in the future.
The answer to his is to add Disability insurance benefits to your life cover, or take them out as a separate insurance.
This will provide financial support to cover the costs of prosthetics and modifications to your home or vehicle, often necessary following the loss of a body part or severe disability.
4. Cancer treatment that costs more than your medical aid limits
Medical aids must cover PMB cancer treatments, but they can force you to use only state hospitals through a scheme treatment plan.
If you want to ensure you have the best cancer benefits, consider a higher benefit plan within your medical aid.
Fedhealth is the only medical aid that allows you to upgrade your plan at any stage as a result of suffering a life-changing illness.
You should also consider adding a Lump-Sum Dread Disease benefit to your life cover, or take separate insurance that helps pay for cancer treatments beyond what your medical aid offers.
5. Ongoing care for disabilities
Some medical aids offer post-hospitalisation care only until savings or plan limits are reached.
If you suffer a permanent disability that requires long-term costs for physiotherapy, rehabilitation, and lifestyle modifications to living spaces, these are typically not covered by medical aids.
Your Solution is to add a Permanent Disability benefit to your life insurance or take out a separate policy just for disability.
This will ensure that long-term rehabilitation costs, home adaptations, and disability aids like wheelchairs are adequately funded, minimizing your financial strain.
6. Protecting your Income
One of the most significant financial risks following a severe illness or accident is the loss of income, both during treatment and afterward.
You may never be able to earn the same amount as you did before your illness or accident.
A medical aid helps cover healthcare expenses, but it does not provide income support over the recovery period or in cases of permanent disability.
Look at taking out Income Protection Insurance, especially if you are the primary breadwinner.
Medical aids are essential but they do have benefit have limits.
By joining a good gap or top-up plan and having sufficient disability, dread disease, and income protection cover, you can ensure comprehensive protection for yourself and your family.
Private healthcare providers can charge up to 500% of medical scheme rates.Medical aids add procedure co-payments as well.
These are significant concerns for medical aid members.
Protect yourself against these potential threats, by joining Cura's GAP or top-up insurance plan.
OR Zest GAP or top-up insurance plan.
This separate insurance will cover most in-hospital claim shortfalls and any co-payments. It is a vital safety net, ensuring you have adequate benefits for medical treatments without bearing the full burden of unexpected costs.
Protect yourself from soaring medical expenses by bridging the gap between medical scheme rates and the charges imposed by private providers.
Specialised Dental treatments can be extremely expensive!The costs of braces, root canal, implants and so on, can run into thousands of rand. Most treatments are done out of hospital, so are funded from your savings. That can result in less money available for other medical needs and family limits being used on one member only!
Dental treatment is something we all need and it is vital you consider the Best Dental Insurance Plan OR Most Affordable Dental Planin South Africa.
No Medical Aid or have a Hospital Plan only? This plan will help you meet the high costs of both normal and specialised dentistry!
083 655 2164
You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions.
We will offer you the best help at no cost!
Medical aid pays healthcare costs.
What if a disability stops your income?
YOUR TRUSTED, QUALIFIED ADVISOR:
Peter Pyburn - Authorised Financial Services Provider, fully licensed to render financial services since 1991. Death and Disability Planning; Retirement Planning; Investment Planning; Healthcare and Estate Planning.More..
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Last update: January 18, 2025