Medical aids were quick to respond to the growing demand for cover from the lower income sector. In recent years we have seen a number of different plans emerge among the big medical schemes that offered cover from as little as R500 per month. Not just hospital and chronic cover – it also included benefits for day-to-day care although it applied only to certain clinics and private doctors that joined the network.
These low cost medical aids were a dream come true for medical aid members who were suffering with the monthly premiums. But as the saying goes, “if it seems to be good to be true, it usually is”.
Firstly it is important to understand that low premiums are only applicable if you earn within a certain bracket that makes it difficult to afford medical aid at the full price. You have to provide proof of your income. Secondly you can opt for these medical aid plans even if you earn above the threshold but you will pay a higher premium. It seemed like a perfect fit. Finally people who wanted medical aid but could not afford it could now enjoy cover.
But before you give up your more costly medical aid, think again. You get what you pay for and even though the offerings on these low cost medical aids may seem attractive, you could find the cover very restrictive when you need medical care. It is more likely to work against you if you are a person who needs medical care on a regular basis.
Medical Aid Refusing Hospital Admission
We have received numerous emails from readers detailing their experiences with some of these low cost medical aid plans. Overall there appears to be consistency in their reports, primarily when it comes to hospital admission.
We have communicated with a pensioner who has a history of cardiovascular disease and was refused hospital admission in December 2012. She was suffering extreme shortness of breath and other symptoms indicative of heart failure, which her GP confirmed to us. But she had to wait 4 days for her medical aid to authorise the hospital admission.
After speaking to the scheme, we discovered that it can take up to 24 hours for them to send the relevant forms to the patient’s general practitioner, and then decide if hospitalisation was warranted. In this case, it took them 3 days to do so due to the weekend and holidays. This despite the fact that the GP and specialist overseeing the condition both recommended hospitalisation for the patient.
Authorisation for hospitalisation is a procedure applicable across the board to all medical aid plans. The problem that appears to arise with these low cost medical aid plans is that the scheme requires copious amounts of paperwork and the input of various “departments” within their organisation to decide if hospitalisation is warranted or not. Often at the expense of the patient’s health, and possibly their life.
There is no doubt that patients and healthcare providers have in the past abused the system, with hospital stays that were unwarranted. But if a pensioner, with a history of heart disease and the sudden onset of serious symptoms can be made to wait for hospitalisation, then there is undoubtedly something extremely wrong with medical scheme procedures.
Stay with Current Medical Aid
South Africans are experiencing the pinch with rising medical aid premiums and diminishing benefits. But there are no alternatives to medical aid. Even the cleverly marketed medical insurance that has entered the market in recent years cannot replace the level of cover of medical aid. But before you switch to cheaper plans, you need to be fully aware of the implications. You cannot reasonably expect to enjoy the full range of benefits of a more expensive plan when you opt for cheaper options.
Rather try to re-work your monthly budget and find a way to keep your current medical aid plan. If you need a cheaper option, then look at other plans but tread cautiously when it comes to the very low cost offerings from your scheme. The reality is that these plans are geared for people who previously did not have medical aid cover, or cannot afford to keep their current cover. Despite its shortfalls, it does save its members the hassles, and at times the horror, of public health services.