Medical bills are a reality check. Picture: Pexels / RODNAE Productions
Medical bills are a reality check. Picture: Pexels / RODNAE Productions

Are you sure you have the best medical cover? Tips to help you choose the right medical aid plan

By Viwe Ndongeni-Ntlebi Time of article published Apr 9, 2021

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South Africans have come together to raise more than R1.5-million for physician and radio personality Dr Sindi van Zyl who has been battling Covid-19-related complications in hospital for weeks.

Last week, her husband, Marinus van Zyl, took to social media where he made an impassioned plea for help to pay her medical bills.

Writing on the Quicket crowdfunding platform, he said: "The cost to the family of the hospital alone has already exceeded one million rand, and we are running out of funds. Dr Sindi cannot breathe on her own yet, and the cost of needing to be on the ventilator alone is around R150 000 per week.

"She has suffered several complications related to a long stay in ICU, and we need more funds to pay for her continued stay in hospital until her lungs can cope without the ventilator. We will use any funds raised to pay the hospital bills, to enable Dr Sindi the chance to survive."

Van Zyl’s medical bills are a reality check and has left many South Africans worrying whether they can afford medical aid or if their medical aid would cover all the medical expenses during these tough and uncertain times. Others may have also reviewed their decision to cut down on medical aid due to tighter budgets.

For some expert advice, we asked the principal officer of Bonitas Medical Fund, Lee Callakoppen, to help us understand the difference between hospital plans, hospital insurance and gap cover:

Medical aid hospital plans

A hospital plan provides you with basic, yet important medical cover.

The product differs from scheme to scheme but, in essence, the plan is offered by a not-for profit medical scheme and will cover you in hospital for emergency and planned procedures.

The hospital plan ensures that if you are admitted into hospital for a procedure or due to an accident or illness, your expenses are covered – within the limits set by your particular plan.

There are 27 chronic conditions that all medical aid plans must cover, so the hospital plan also covers these which are known as Prescribed Minimum Benefits (PMBs)

This type of plan does not cover day-to-day medical costs like visits to the doctor, specialist or medicine and it is tax deductible.

Hospital insurance

Hospital insurance is not a medical aid, it pays you for the time you spent in hospital but not for the treatment you receive.

It provides cash benefits, depending on the number of days you are in hospital due to illness or an accident.

The insurer pays the money directly to you. You are able to use the money however you please – to pay for daily household costs or the hospital, doctor and specialist bills.

This often seems more attractive than a hospital plan and has a cheaper monthly premium. However, the daily amount you receive is often way below the medical expenses incurred while in hospital. It is governed by the short or long-term insurance legislation.

It does not cover PMBs

Hospital insurance may include personal accident risk cover such as disability and loss of limbs, inability to work, salary protection, death and/or funeral cover and is not tax deductible.

The limitations of hospital insurance:

  • It is a set amount which might not cover your hospital or medical bills, leaving you financially short and, in some cases, it has a waiting period.
  • New regulations state that payouts are limited per insured life, per hospital stay with an annual limit.
  • Typically, people buy the policy that pays less than R1 000 a day. If you have one of the top plans, the daily payout during your stay in hospital may sound like a lot of money however, it usually falls short of the costs charged by hospitals, doctors and specialists. For example, a Caesarean birth costs around R30 000. This could be more if complications occur. Remember that hospital insurance companies are “for profit”, unlike medical schemes who are “not for profit”. The recommendation by most financial advisers is that a hospital insurance product should be used in conjunction with a medical aid or a hospital plan and as income replacement rather than medical aid cover.

GAP cover

At times, there might be a shortfall between what the medical scheme pays and what the hospital or specialist charges. You are responsible for paying the difference.

There is an insurance policy called gap cover which you can take out to pay for the shortfall.

The amount you receive depends on your policy but there is an overall annual limit.

Some gap cover policies have a waiting period for certain conditions.

Most people usually take gap cover together with a medical aid hospital plan.

It is important to know that gap cover, like hospital insurance, is an insurance policy and is registered as a short-term insurance policy.

Gap cover premiums are not tax deductible.

No matter what the future holds, at some point you or a family member will need medical attention. It’s important that you consider all factors when choosing health cover, and make the right decision for your wallet and your health – your life could depend on it.

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