Finding cost effective medical cover

2014-10-07 08:00

Multimedia   ·   User Galleries   ·   News in Pictures Send us your pictures  ·  Send us your stories

Medical scheme membership can be an expensive exercise, no matter who you are. For a single mother of three, finding the right option can be daunting. Maya Fisher-French unpacks the options

Elizabeth is a mother of three young children aged three, six and nine.

She has a take-home pay of R15?000, with which she has to fully cover the costs of the medical scheme as her partner does not have a regular income.

We investigated what cover the larger medical schemes would be able to provide, given her income and her need for cover for her partner and three children.

What was clear was that a basic hospital plan was the most affordable option for Elizabeth, although, for an additional R1?000 to R2?000 per month in most cases, she would be able to move on to a more comprehensive plan.

Fedhealth Maxima EntryZone

Total cost: R2?653(increases to R2?958 in 2015)

This plan will provide unlimited private hospital in-hospital cover at a network hospital and unlimited cover for 27 chronic conditions. It does not have any medical savings to cover day-to-day expenses such as GP visits.

A great feature of this product is that should Elizabeth or her children be diagnosed with a dread disease or have a life-changing event, she could upgrade at any time of the year within 30 days of diagnosis.

This means she is not locked into an option and can upgrade should something dramatic happen that changes their circumstances during the year.

Fedhealth charges the child rates up until the child turns 27, providing they are still studying or otherwise financially dependent on their parents.

Fedhealth covers additional out-of-hospital expenses, including specialised radiology such as MRI and CT scans. Trauma treatment in casualty is also paid from risk (by the scheme).

This is a great benefit for young families like Elizabeth’s, where small children are prone to injuries like fractures and cuts that need stitches.

After a hospital event, Fedhealth pays for treatment like physiotherapy, occupational therapy, speech therapy, pathology and general radiology for up to 30?days after leaving hospital, from risk (by the scheme).

Upgraded cover:

If Elizabeth wanted cover that included day-to-day expenses, the most cost-effective option from Fedhealth would be the Maxima Saver option for R4?285 (increasing to R4?689 in 2015), which would include R5?472 for day-to-day medical expenses.

Liberty Medical Scheme Gold

Focus Select

Total cost: R3?408

This would provide Elizabeth and her family with hospital cover at Liberty Medical Scheme’s network of hospitals for non-emergency procedures and receive any chronic medications from state facilities.

The plan also covers emergency room visits as well as medical expenses as a result of crime.

There is also a preventative core benefit that covers the cost of medical preventative tests such as mammograms, and cholesterol and prostate tests.

The scheme also pays for out-of-hospital MRI and CT scans.

Upgraded cover:

The Saver Select option for R4?240 per month would include an additional R6?336 per annum for day-to-day expenses.

This is a family option and includes cover for a free dental checkup for each of her children once a year.

Should any of her children develop a childhood chronic condition, the plan would pay for medication for eczema, acne, ADHD and allergic rhinitis.

Bonitas BonEssential

Total cost: R3?149

This option would provide 100% cover for hospitalisation as well as covering the prescribed minimum benefits. In addition, family members would receive a free flu vaccination and HIV test per year, and each child would have one free GP consultation a year.

Discovery Essential Delta Core

Total cost: R3?278

Elizabeth would be covered in full at hospitals in the Delta hospital network. For planned admissions at any other private hospital, a co-payment would apply.

The plan guarantees full cover in hospital for specialists who have a payment arrangement with Discovery, otherwise Discovery pays up to 200% of the Discovery health rate for other healthcare professionals.

All 27 chronic illnesses that fall under prescribed minimum benefits are included, as well as cover for medical emergencies when travelling.

Momentum Health Custom option:

Total cost: R2?755 – R3?742

Elizabeth and her family would receive unlimited hospital cover and cover of up to 100% of Momentum Health rates in hospital.

They will also have access to various free screening and preventative check-ups and annual health assessments.

The lower monthly premium assumes Elizabeth uses a hospital network and receives chronic medication from a state facility.

If she or her children suffer from a chronic condition it would be advisable to opt for cover where they receive medication from one of Momentum’s preferred providers, although this would increase the premium.

So depending on the cost, it may make more sense to opt for the lower premium and either pay for the medication from your own pocket or from Momentum’s HealthSaver.

A great feature with Momentum Health is you can earn money towards health expenses. This means the family could also receive up to R10?800 a year in day-to-day healthcare expenses by maintaining a healthy lifestyle.

All members have free access to HealthReturns, an incentive programme which rewards a member and adult partner based on their lifestyle and level of activity.

Adviser’s recommendation

Financial adviser Duncan Barker recommends that Elizabeth considers Medihelp Dimension Prime?1, which would cost her R2?220, as she will only pay for two children.

This will provide full hospital cover, as well as R2?250 for doctor visits and R1?060 for medication.

Barker recommends Elizabeth also includes gap cover with Stratum Gap?500 for R112 a month.

“This would give her medical cover for just under R2?500 per month, and provide vital hospital cover and some savings for those inevitable doctors’ visits with kids,” says Barker.

Gap Cover

This cover pays for the shortfalls that might occur on doctors’ and specialists’ accounts when hospitalised or where certain out-patient procedures are performed.

Gap cover policies have been under review by National Treasury and the first draft regulations have proposed banning gap cover products as they were in effect carrying out the business of a medical scheme.

But after consultation, it was clear there is a role for gap cover to provide a low-cost solution to meeting bills not covered by medical aid.

The compromise is that these policies can continue, provided they operate within a framework where there are strict product parameters and monitoring by the Financial Services Board.

Gap cover may also only be provided to insured persons who are members of a medical scheme. It is seen as an enhancement and not as a replacement.

Shop around

When selecting your medical scheme, consider the following:

What are the benefits for children?

Some medical schemes like Fedhealth have an unlimited GP benefit for consultations at a nominated GP on the Fedhealth network, even after your savings are used up.

Liberty Medical Scheme provides extended chronic cover for childhood illnesses such as eczema, acne, ADHD and allergic rhinitis.

Find out if visits to the emergency room for the inevitable stitches are covered from risk or day-to-day savings and until what age you still pay child rates.

Fedhealth charges the child rates up until the child turns 27, providing they are still studying or otherwise financially dependent on their parents.

What is paid for from risk?

The less you have to pay from day-to-day savings, the better the benefit. Schemes like Liberty, Fedhealth and Bonitas cover MRI and CT scans from risk. Find out if trauma treatment, preventative care and contraceptives are paid from risk.

What is the chronic cover?

All medical schemes must cover the 27 prescribed minimum benefits, but some plans provide extended cover for up to 69 chronic conditions. If you suffer from a chronic condition that is not a prescribed minimum benefit, you need to find out if it is covered.

Does the scheme have a network hospital near me?

Most schemes offer a substantial discount if you use their hospital networks for non-emergency hospitalisation.

Talk to us

What percentage of your take-home pay do you spend on medical costs?

Join the conversation! encourages commentary submitted via MyNews24. Contributions of 200 words or more will be considered for publication.

We reserve editorial discretion to decide what will be published.
Read our comments policy for guidelines on contributions. publishes all comments posted on articles provided that they adhere to our Comments Policy. Should you wish to report a comment for editorial review, please do so by clicking the 'Report Comment' button to the right of each comment.

Comment on this story
Comments have been closed for this article.

Inside News24


Book flights

Compare, Book, Fly

Traffic Alerts
There are new stories on the homepage. Click here to see them.


Create Profile

Creating your profile will enable you to submit photos and stories to get published on News24.

Please provide a username for your profile page:

This username must be unique, cannot be edited and will be used in the URL to your profile page across the entire network.


Location Settings

News24 allows you to edit the display of certain components based on a location. If you wish to personalise the page based on your preferences, please select a location for each component and click "Submit" in order for the changes to take affect.

Facebook Sign-In

Hi News addict,

Join the News24 Community to be involved in breaking the news.

Log in with Facebook to comment and personalise news, weather and listings.