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The difference between Medical Aid and Medical Insurance?

These days medical aid seems to be a luxury that is only affordable to the rich. Since medical insurance entered the scene, the number one question asked by the public is; what is the difference between medical aid and medical insurance?

When searching for an affordable medical aid, one will come across many different options; each with their own positives and negatives.

Most people want the cheapest medical aid rates, with the most extensive cover. However, medical aid plans that cover the client fully are usually very costly. Then, there is the issue of gap cover, which covers the shortfalls that medical aids don’t see to.

Medical aid, which is regulated by the Medical Schemes Act is essentially:

  • It pays in-hospital benefits according to the National Recommended Price List limiting benefits as per the plan.
  • Cover that is based on tariff codes and procedures;
  • It often has a shortfall due to the difference between the National Recommended Price List and the South African Medical Association rates which is what healthcare professionals charge;
  • It must, by law, cover Prescribed Minimum Benefits;
  • It has specified and yearly limits for procedures and health events do not need to be specifically stated;
  • It does not include any personal accident disability and loss of limbs cover;
  • It is not authorised to include death and/or funeral cover as part of the Medical Aid Scheme; and

What is medical insurance, and how does it differ?

Medical insurance tends to focus on major life events. It may not cover pre-existing conditions, but is helpful in case of accidental injuries, paralysis or illnesses that may occur after the insurance policy has commenced.

These include things like hospitalisation and larger life events. If, for example, you are covered by insurance and suddenly experience a stroke or heart attack, medical insurance will pay out, in the same way that your car insurance will pay out if your car got stolen.

Medical insurance pays stated Rand amounts for stated events/conditions, any costs over and above the stated benefit amount are the member’s/patient’s responsibility.

Medical insurance has much more affordable premiums, meaning it is accessible to all.

Medical Insurance is regulated by the Long-term Insurance Act. It:

  • Covers certain accidental injuries, such as disability;
  • Can cover your salary when you’re unable to work as a result of accidental injury;
  • Gives you the option of including death and/or funeral cover on your plan;
  • Offers stated benefits and an official list giving details of prescribable medicines.
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