Having medical aid cover does not mean that you are protected all year round for private healthcare irrespective of the cost. All medical aids cap the out-of-hospital benefits although many schemes offer unlimited benefits for hospitalisation and emergency services.
There is no medical aid that offers unlimited benefits for your day-to-day medical expenses. With a medical aid, like any financial product, you get what you pay for and if you are prepared to spend a little more, you can rest assured of unlimited in-hospital cover but within certain restrictions as well.
Unlimited Day-to-Day Benefits
Your medical aid allocates a specific annual benefit to cover your out-of-hospital expenses or you may be contributing toward a medical savings account every month. This benefit needs to be carefully managed to ensure that it lasts you for most of the year, and with savings, possibly carry some over to the next year. If your out-of-hospital benefit is always exhausted before the year end, you may have to consider higher cover.
Unfortunately there is no medical aid that offers you unlimited out-of-hospital benefits for all medical services. Some schemes may have plans where you can visit a specific clinic network as often as necessary but this does not allow you unrestricted spend on your day-to-day benefit.
Medical aids have to pool the contributions of all members and allocate benefits according to your monthly contribution. Schemes bank on the fact that younger, healthier patients will require less healthcare services in a year than the older members. It is therefore unrealistic to expect any medical aid to provide unlimited benefits for out-of-hospital services. Apart from being financially impossible to balance, it may also be abused by either the patient or practitioner and be open to fraudulent activities.
Unlimited Hospitalisation Benefit
These days many medical aids are capitalising on marketing their unlimited benefits for hospitalisation and emergency services. While most medical aid plans will cover all your emergency medical expenses irrespective of the costs, this is only applicable in situations that are deemed a life and death situation.
Unlimited hospital benefits can often be misleading. It does not cover non-essential or elective procedures and the medical aid may still impose a limit for certain procedures in that the procedure may not be repeated a certain number of times. You still have unlimited hospital benefits if you are admitted for different types of procedures.
In addition, doctors or medical specialists who charge above the National Health Reference Price List may not be fully remunerated and you are still responsible for the price difference. Fortunately there are now some medical aid plans that do cover up to 300% of the NHRPL rate for costs incurred in hospital.
It is important to be fully aware of the type of medical aid cover that you are purchasing. Even if a certain plan claims to offer unlimited benefits for hospitalisation, the onus is on you the member, to clarify whether this applies to all procedures and verify if you would be held liable for any co-payments.