As the surge of winter sets in, alongside the general happenstance of life, healthcare expenses may cause a slight rise in your blood pressure.

Getting the right medical insurance is one of the most indispensable expenses to ensure that you and your family’s healthcare needs are met.

Here are some basic guidelines and concepts to help you finding the right medical cover easily.

Hospital plan vs. medical aid scheme

If you’ve ever been at home during midday, you would have seen an array of television commercials talking about hospital cover plans. These ads explicitly state their distinct nature from medical aid schemes. So, what’s the difference?

According to Health24, there are two main differences. A medical aid scheme provides mostly unlimited hospital cover, as well as day-to-day medical benefits as stated by the provider. Most providers have an overall annual limit, depending on the type of medical plan you choose. Hospital plans, on the other hand, require you to cover almost all of your day-to-day, out-of-hospital costs yourself (depending on the plan), and hospital plans come at a significantly lower rate than medical schemes.

Considering you and your family’s healthcare needs is essential when choosing the right medical cover, but you’ll need to decide which medical plan suits your needs and your pocket. Choosing between a hospital plan and a medical aid scheme means deciding whether you can afford to pay the normal daily medical expenses yourself. If not, you might have to opt for comprehensive hospital cover.

Assessing your finances is an important part of choosing the right medical plan. Here are a few things to consider, and some terms you need to understand:

In-hospital percentage

This refers to the amount of cover your medical provider will pay for in hospital procedures. The higher the percentage or need for hospital procedure required, the more you will have to pay out.

Overall annual limit

This is the overall limit that the medical aid is prepared to cover for the year, inclusive of all medical procedures, events and costs.

Above threshold benefit

This is a threshold amount set by the plan every year: the prescribed limit of out-of-hospital medical expenses that must be reached before your medical aid starts to assist with medical expenses again. The accumulation of benefits, up to this limit, is done at 100% of the medical scheme rate, and once you’re in the above threshold benefit, benefits are only payable at between 80% and 100% of medical scheme rate.


This refers to the selected network of hospitals, doctors, specialists or pharmacies which are chosen by your medical plan. Your medical provider will have negotiated favourable rates with them, and would seek medical help from this network only. Should you not be in reach of your network for any reason, or you find yourself in an emergency, your provider may make allowances outside of this network.

Medical savings account

This is an amount of money set aside by your plan for your out-of-hospital expenses. This account is funded by your premiums. An annual amount is allocated for the calendar year in advance, in January of every year. All out-of-hospital expenses are funded from this account until it is depleted.

Out-of-hospital expenses benefit

This is almost like a savings account provided by your plan. It is also used to fund out-of-hospital expenses for the year, and made available in January of every year.

Self-payment gap

The gap that exists between the amount of money that is provided in your ‘savings’ account and/or out-of-hospital expenses benefit, and the threshold set by your plan. You will be expected to cover all your own out-of-hospital medical expenses whilst you are in the self-payment gap period.

Complete cost

This is the overall cost of having this scheme. This cost is the total amount which the member will be asked to pay in a year, and excludes any additional costs that you may have to bear for hospital procedures.

Scrutinising a medical scheme provider’s benefits may help you avoid an unfavourable bill at the end of the month. This includes checking the prescribed medical benefits (PMBs) and the exclusion time, which is a limited period of time during which you cannot claim from your medical provider. Additionally, there are many online comparative sites that will help you compare and choose quotes across medical aid schemes.

About The Author

Chwayita January

Chwayita January, or ‘Ceejay’ for short, is an Honours student in Media Studies and our resident social media and copywriting assistant. Ceejay is a self-deprecating aspiring writer, with a twang that will make you question her nationality.

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