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Ensure you get the right medical scheme cover for you and your loved ones.



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With the public health sector in our country being stretched and often under-resourced, the preference for most South Africans is to have medical scheme membership, giving them access to private healthcare benefits.
The medical scheme pays for the member’s medical costs, with the coverage and payment of the healthcare specifically stated by that medical scheme.

Who to choose?

There are various medical aid plans and options available to members – hospital plans, hospital plans with a savings account, traditional plans, comprehensive plans or network plans. The selection thereof can be daunting and complicated especially as each option and plan differs in cost.

Medical aid scheme versus medical or health insurance

It’s important not to get confused by medical aid schemes and medical insurance. There is a significant difference.  A Medical Aid Scheme is governed by the Council for Medical Schemes and it’s a non-profit organisation which must according to law cover a list of Prescribed Minimum Benefits (which are the diagnosis, treatment and care linked to a list of 270 health conditions and 25 chronic conditions). It also covers in-hospital treatment according to the set medical scheme tariff and as per the National Recommended Price List. The rest of the benefits that are part of the different options are determined by the scheme itself and vary in the monthly contributions linked to those options and benefits.  To find out about gap cover policies and how it can work with your medical scheme , click HERE. Medical Insurance is a long term insurance product, governed by the Financial Services Act. The client takes out insurance against the risk of incurring certain medical expenses.  It’s important to note that medical insurance covers health events at fixed or very tightly defined amounts and it is paid to the client directly and not to the medical service provider.  Medical scheme members are often advised to also invest in a complementary medical insurance product such as gap cover. Because medical service providers are allowed to charge more than the medical scheme tariff (up to 500%), a medical shortfall amount could occur, which would be for the patient’s own account. A gap cover policy would cover that shortfall for in-hospital procedures.  One should however be careful not to only invest in a medical insurance product such as a hospital insurance policy. The initial monthly contribution for hospital insurance could seem to be a lot more cost effective than a medical scheme membership, but hospital insurance cover is fixed pay-outs and will apply cover as set out in the specific policy schedule. It is very important to understand what exactly you are covered for should an unforeseen health incident occur.  To compare medical schemes based on your specific needs and budget – click HERE. 

Medical schemes and health cover: Which one is right for me?

In South Africa there are a number of medical aid plans available. Members can choose between hospital plans, hospital plans with a savings component, traditional plans, comprehensive plans and network plans. All of these range in the benefits offered and, of course, the price. If you want the most affordable medical aid that fits your healthcare needs, you need to understand what the product has to offer before you join.  Basic hospital plans are recommended for an active and healthy family. If you take responsibility for your own health and know that prevention is better than cure, it could be the viable option to consider. However, the disadvantages include co-payments on certain procedures such as gastroscopy, colonoscopy, laparoscopy, extraction of wisdom teeth, cataract removal, etc. Some procedures might also not be covered at all.  (More members these days choose to have a basic hospital plan with a gap cover policy as complementary health cover product. For more information on gap cover, click HERE).  Comprehensive plans are medical scheme membership with a savings component and covers almost all medical expenses and include benefits for in-hospital, day-to-day expenses and chronic medication. These benefits are subject to the rules of the specific scheme and are recommended for individuals or a family who needs (and can afford) comprehensive cover for emergencies, hospitalisation, day-to-day expenses and who makes use of quite a lot of chronic medication. Traditional plans don’t have a savings component and gives you a set number of benefits linked to a certain category (as determined by that specific medical aid). The members could therefore still get benefits for in-hospital, day-to-day expenses and chronic medication, but it’s limited. These plans are recommended for families with children, who know they have certain benefits that they will regularly use (GP visits, basic dentist visits and buying over the counter and prescription medication). Even if a certain benefit runs out through the year (which you will have to pay out of pocket), the plan will still cover other set benefits such as emergencies, hospitalisation, etc. Hospital plans with savings cover accounts (New Generation Options) are an alternative to the traditional plan. A certain amount of money is debited into your medical scheme account, and the member can choose how to allocate the money further, i.e. GP visit, optometry, medication, physiotherapy, etc. Once the amount is finished, you’ll have to fund any day-to-day benefits yourself. There are also combinations of a traditional and new generation option available, which makes the selection process even more complicated. The benefits and options of each medical scheme can also be slightly different. The best way to select the medical scheme option that is best for you and your family is to get advice and recommendations based on your specific needs and budget.  Request your medical aid quote online and an accredited healthcare broker will contact you to discuss and assist you with the comparison and different options available so you can make an informed decision. 

How does health cover and medical aid schemes work?

It’s a reality for SA residents: If you want the best and quickest medical treatment should you or your loved ones get ill or injured, then you need medical scheme cover. Medical scheme membership helps with the payment of healthcare needs such as doctor and dentist visits, surgery and other hospital procedures, etc. To access medical aid cover you need to pay monthly premiums based on the specific option and list of benefits you chose. The medical schemes in South Africa are non-profit organisations and must be registered in accordance with the Medical Scheme Act. The medical schemes differentiate themselves with regards to the options and benefits they offer within their selective plans. All medical schemes must however according to law provide a minimum set of benefits to its members (i.e. Prescribed Minimum Benefits or PMBs). A Board of Trustees that are elected by the scheme’s members are the responsible body that manages to scheme on behalf of its members. Members should ensure they join a medical scheme that are financially sound and are able to deliver when members need to claim. The Council for Medical Schemes regulates the medical schemes in South Africa and members can consult with them regarding any scheme issues. In South Africa we have two types of medical schemes: Closed medical aid schemes These schemes are only open to a particular employee groups within a company, profession, trade, industry, association or union that have established a scheme exclusively for their personnel and /or members. Open medical aid schemes These schemes are open to the public. There are currently 26 open medical schemes in South Africa. Their benefits are much more innovative. Some of the top open medical aid schemes in South Africa: Bestmed Bonitas Discovery Fedhealth Genesis Keyhealth Liberty Medihelp Medshield Momentum Health Profmed Resolution Health Sizwe Spectramed Topmed   To see which open medical scheme would be the best fit for your healthcare needs, click HERE.