MEDICAL COVER: WHAT YOU NEED TO KNOW

The right advice really helps when selecting medical aid that suits your needs. Here's what you need to know.

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Medical aid is a must in South Africa for anyone looking to make use of private healthcare, as the cost for this type of care is simply out of reach for those who aren’t members of medical schemes.

However, complicated co-payments, sub-limits and medical expense shortfalls have become increasingly common, leaving people out of pocket even when they do have medical aid. As a result, gap cover has become an essential part of a comprehensive healthcare portfolio – but selecting the right product can be daunting.

We asked insurance expert James White of Turnberry Management Risk Solutions to break it down into the most important things to consider.

STEP 1: CHOOSING A MEDICAL AID
Selecting a medical aid scheme and plan option is a personal exercise – there are a number of different offerings available from multiple providers, and everyone has unique needs. The right plan depends on your individual circumstances, such as your age, life stage and your health.

For example, a single, healthy 26-year-old with no children will have very different medical needs to someone in their mid-50s with a chronic condition like blood pressure or diabetes. A basic hospital plan might be sufficient for the 26-year- old, while the person with the chronic condition will need more comprehensive cover. At the same time, a 26-year-old who is planning to start a family or who already has children will also have different requirements from their medical aid.

Selecting a plan also depends on what you can afford and personal budget factors, as the cost of medical aid can be a significant monthly expense. It is important to consider any limitations, additional expenses, exclusions or waiting periods that could apply which, again, depends on your circumstances.

If you feel confused when reading through the many different options, consider speaking to a broker or financial advisor who will easily be able to filter through the plans available and help you make the right decision for you.

THERE IS NO SINGLE SOLUTION THAT WILL FIT EVERYONE’S CIRCUMSTANCES... EVERYONE IS DIFFERENT, AND GETTING THE RIGHT FIT FOR YOU IS THE KEY TO PROTECTING YOUR FINANCIAL FUTURE.

STEP 2: FILLING THE GAP
Once you’ve selected a medical scheme option, the ‘holes’ in your cover can be plugged with a gap cover policy, which is an add-on to the medical aid option you’ve chosen. Even if you have chosen the most expensive comprehensive medical aid option, there may still be gaps – be aware of this and find out what they are.

There are three core components of gap cover, but the most important one covers any shortfalls when you go to hospital. This is where most out-of-pocket expenses originate.

The other two components are co-payments (where you are expected to cover part of the cost of a specific treatment or procedure) and sub- limits (where medical aid will only pay up to a certain amount for a specific procedure). Again, be aware of any exclusions, limitations and waiting periods of the gap cover provider.

If your chosen medical aid plan includes large co-payments, then your gap cover should have substantial co-payment cover. All medical aid schemes and options differ when it comes to hospital shortfalls, sub- limits and co-payments, so it is vital to find a gap policy that fits well to supplement your medical plan.

Gap cover providers may also offer a range of value-added extras, including a casualty benefit to cover the expenses of a visit to the emergency room, counselling benefits and premium waivers. Again, the advice of a broker or financial advisor will be handy in helping you select the right gap cover to suit your needs and your chosen medical scheme plan.

DON'T RUSH INTO A DECISION
There is no single solution that will meet everyone’s circumstances, lifestyle, life stage, age, budget and other needs. Everyone is different, and getting the right fit for you is the key to protecting your financial future.

Expert advice can go a long way in making sure you have the best medical aid cover you can afford – the services of a broker are included as part of medical schemes, so there are no additional fees for making use of this service. The broker can also help find the most appropriate gap cover.

Before you sign any contracts, make sure you’ve considered all your options, have had all your questions answered and made the right selection for you, your family and your budget.

Text: Courtesy of Balanced Life Magazine
Photo: Gallo Getty/Images