With the introduction of new regulations in April last year, the health insurance landscape significantly broadened South Africans’ access to medical cover.
Historically, health insurance providers could refuse to cover individuals based on a number of factors, including age, disability or health status.
The introduction of the demarcation regulations, which now prohibit this form of discrimination, has unlocked access to medical cover for low- to middle-income earners who might previously have believed that it was beyond their grasp.
People often believe that medical aid is the same thing as health insurance, however, in reality, the two are very different.
Before choosing between medical aid and health insurance, it is important to understand the differences and benefits of each product type.
Previously, only medical aids were obliged to provide all applicants with cover, however, the new regulations make it mandatory for health insurance providers to grant cover as well. In both cases, however, a three-month general waiting period and a 12-month pre-existing condition exclusion can be imposed.
The intention of insurance is to protect people against unforeseeable circumstances. These restrictions prevent individuals from only taking out insurance when they know that they are likely to require medical treatment, and then cancelling the policy immediately after treatment.
PAYING FOR COVER
Medical schemes must charge all members of a given plan the same premium and cannot adjust the rate based on risk factors such as age, medical history, lifestyle or health status.
Prior to the introduction of the demarcation regulations, insurance products could vary the amount charged based on these considerations. However, they are now required to charge all members equal rates.
Higher premiums may, however, be charged to members according to the age at which they enter into an insurance agreement, provided the same charges are applied to all members taking out cover within that age category.
WHAT YOU ARE COVERED FOR?
Medical aids are required by law to provide all their members with a minimum level of mandatory cover called prescribed minimum benefits, which cover treatment for 26 of the most commonly occurring ailments and more than 270 other conditions.
Insurance providers, on the other hand, are not obligated to provide a minimum set of benefits or to provide cover for common or expensive treatments. This means that health insurance products can be priced at a more affordable rate.
Policyholders must carefully read their policy document to ensure that they know what they are covered for.
PAYMENT OF CLAIMS
Medical aid providers will pay medical bills on behalf of a member. This might include paying for hospitalisation, medical procedures, doctor’s consultations and certain medications.
They pay medical aid rates, which should sufficiently cover costs. However, sometimes specialists charge more and, in this case, gap cover can be taken out to fund any shortfall between the amount covered by the medical aid and the medical service provider’s charge.
On the other hand, medical insurers are prohibited from paying medical institutions directly for medical expenses. Instead, a daily amount of up to R3 000 or a lump sum of up to R20 000 a year can be paid to the principal member directly for non-medical expenses incurred due to hospitalisation.
It is up to the beneficiary to decide what to do with the money.
Although health insurance differs from medical aid, its affordability makes it more accessible to low- to middle- income earners. The introduction of new regulations now mean that more people can enjoy its benefits.
Visser is the CEO of African Unity Life