Medical Aid
A medical scheme is not an insurance policy, and the difference decides what happens to you in a hospital. A scheme is a not-for-profit fund: it cannot turn you away for being ill, everyone on an option pays the same contribution regardless of age or health, and it pays providers for treatment. Health insurance is a policy that pays a stated amount when something specified happens. Both are useful. They are not alternatives to each other.
Written forHouseholds choosing an option for the first timeMembers whose claims have outgrown their optionEmployers arranging cover for staff
We place scheme membership alongside the cover that sits on top of it, and the reason to use a broker here is not price: contributions are filed with the regulator and identical wherever you buy them. It is that thirty-odd options across the open schemes differ in ways the brochures are not designed to make comparable.
What this typically covers
The main cover. Because every scheme charges the same rate to everyone on an option, choosing one is not a price comparison, it is a question of which option's rules fit the way your household uses healthcare in practice. That is where the work is.
Registered open-scheme options selected against claims history, chronic needs, provider preference, and the network restrictions attached to the contribution.
Specialists may charge several times what your scheme pays, and the difference is yours. Gap cover pays that difference. It is the single most common reason a member with good cover still gets a bill they were not expecting, and it costs a fraction of the scheme contribution.
A short-term policy meeting the shortfall between a scheme's tariff and what a specialist actually charges, within the annual limit prescribed for demarcation products.
The cheapest way onto a scheme. It answers for the thing that would bankrupt you and nothing else, so GP visits and medicine come out of your pocket. It suits someone healthy who wants protection rather than convenience.
Options covering in-hospital treatment and prescribed minimum benefits, without day-to-day cover.
The part nobody explains. Your savings account empties, and then you pay everything yourself until your claims reach a threshold, after which the scheme starts paying again. That middle stretch is the self-payment gap. Knowing roughly when you will hit it is the difference between budgeting for a year and being ambushed in August.
Medical savings account, self-payment gap, and above-threshold benefit, modelled against expected day-to-day claims.
Every scheme has to cover a defined list of serious conditions and emergencies in full, whatever option you are on. It is the floor under the whole system, and it is worth knowing it exists before you accept that something is not covered.
Registration for chronic conditions and the statutory minimum benefits every scheme must fund in full.
Who you can put on your membership and what each person adds. Adding a parent later in life is where the penalties bite, and it is worth understanding those before the situation arrives rather than after.
Adult and child dependant rates, late-joiner penalties, and the effect of moving dependants between options.
What this will not cover
Waiting periods on joining
A scheme may apply a general waiting period, and a longer condition-specific one for anything you already have, when you join or move. This is set by the Medical Schemes Act rather than by the scheme, so no broker can negotiate it away. What we can do is make sure you know it applies before you resign from existing cover.
The late-joiner penalty
Someone who joins a scheme for the first time later in life pays a permanent surcharge on their contribution, scaled to the years they were not a member. It does not fall away. It is the strongest argument for joining earlier than feels necessary.
Gap cover is not a second medical aid
It meets shortfalls on claims your scheme has already accepted. It does not cover treatment the scheme declined, it does not work without a scheme underneath it, and it carries its own annual limit set by regulation.
What we are paid, and by whom
The broker fee a scheme may pay is capped by the Council for Medical Schemes and reset annually, it is the same whichever scheme you choose, and it covers both signing you up and looking after you afterwards. A scheme may not pay an unaccredited broker at all.
When you claim
Authorisation before admission, not after
A planned admission needs a pre-authorisation number from the scheme before you go in, and an emergency admission has to be authorised within the window the scheme's rules state. Without it a share of the account moves onto you, and nothing done later undoes that.
Prescribed minimum benefits are a right, not a concession
If the condition is on the PMB list, the scheme must pay for its diagnosis, treatment and care in full at a designated service provider. That obligation does not depend on your savings being intact or your day-to-day benefits still being available.
The shortfall is a separate claim
What a specialist charges above the scheme rate is not the scheme's problem, it is the gap policy's. It is submitted separately with the scheme's remittance advice attached, and only a policy that was in place before the treatment can answer it.
Frequently asked questions
No. Medical scheme contributions are filed with the Council for Medical Schemes and are identical whether you join through a broker, through the scheme directly, or through an employer. The broker fee is paid by the scheme, capped by the regulator, and the same across every scheme, which means there is no version of this where a broker earns more by steering you somewhere.
It is the stretch between your medical savings account running out and your claims reaching the threshold where the scheme resumes paying day-to-day costs. You cannot avoid it on an option that has one, but you can predict roughly when it starts from last year's claims, and on some options a different structure removes it entirely. That modelling is most of what choosing an option involves.
No. Open schemes must accept any applicant regardless of health, and they must charge everyone on an option the same contribution regardless of age or condition. What they may apply is a waiting period, and for someone joining a scheme late in life, a permanent late-joiner penalty.
It depends entirely on what you spend out of hospital. For someone young and healthy it is often the rational choice, because the thing worth insuring is the catastrophic event rather than the GP visit. For a household managing a chronic condition it usually is not. We work this out from what you actually claimed last year, not from a profile.