Frequently asked questions

What is a medical aid scheme?

A medical scheme complies with the conditions and regulations as set out in the Medical Schemes Act No. 131 of 1998, and is also registered as such.
By paying the monthly contributions as part of these registered medical schemes provides the member with financial means to pay for their health care needs such as hospital procedures, emergency care, doctors’ consultations, etc.
It also gives the member access to private healthcare delivered instead of making use of the government’s medical facilities which are often under-resourced and running over-capacity.

Which medical scheme should you select?

There are more than 20 open medical schemes available to South Africans. Not all medical aids are available to the public – some are “closed” and only available to employer groups in specific organisations.
To select the best medical scheme you need to take your healthcare needs and budget into account. The plans and options that are part of each medical scheme often change and differ from year-to-year and it is therefore wise to compare those options and benefits thoroughly before you join.
Making use of a healthcare consultant or medical scheme intermediary that can help you with the selection process is advisable.

Medical scheme membership is expensive; will they pay out all my medical claims?

No, your benefits will depend on the specific plan and option (linked to a specific monthly premium) you select for your membership.
But, according to the Medical Schemes Act of 1998 all medical schemes must pay for the treatment on the list of 270 conditions and procedures called prescribed minimum benefits (PMBs).

What are my rights as member of a medical scheme?

    The Medical Schemes Act (No 131 of 1998) stipulates: 
  • Standard-rate fees applies for all people joining medical schemes whatever their age or health condition
  • A medical scheme is not allowed to discriminate against people because of their health conditions or already diagnosed illnesses.
  • The principal member of the medical scheme can have dependents as part of his/her specific plan and option and that includes spouses, life partners and natural or adopted children.

And if I’m not happy or have a problem/complaint?

The Medical Schemes Act makes provision for a complaints procedure for people who with complaints against a medical scheme.
The Council for Medical Schemes is the statutory body that provides and oversees the regulations and the complaints process for members of a medical scheme.
It is recommended that medical scheme members use their health broker’s when they have a complaint or claims issue with their medical scheme. This would provide the member with the necessary support and access to specialist medical scheme knowledge when liaising with the scheme as well as the CMS. To appoint a health broker is at no additional cost and is a service available to all members of an open medical scheme. Visit www.medxpert.co.za for more information and to activate your medical scheme advice and support services.