Healthcare schemes unpacked – do adequate research before selecting the right medical cover option.


Given the plethora of medical insurance schemes, hospital plans, and medical aid products being marketed to the average consumer, it may be difficult for some to decide which option would best work for them.

Consumers are thus advised to do their homework thoroughly to ensure that they choose the right medical cover for themselves and their families, based on their specific financial and healthcare requirements. Choosing the wrong scheme could have dire consequences, not only in terms of payment shortfalls but also in terms of the benefits available.

It is therefore important to unpack the various medical schemes and plans available and demystify the choices that consumers face. Your financial situation will largely dictate the best option between medical health insurance, a hospital plan and medical aid. However, selecting a reputable medical aid and a premier gap cover will ultimately give you the maximum amount of coverage. Here is a breakdown of the various medical cover options and their benefits, starting at the lower range of coverage:

Medical health insurance

Medical health insurance provides basic cover for General Practitioner (GP) visits, dentistry, x-rays, and accident cover. Essentially, this helps patients skip the long queues outside government healthcare facilities. It provides access to private healthcare for these services, but it does not provide cover for in-hospital procedures at private healthcare providers. In those instances, the insured will still be required to make use of government hospitals, or to pay the private healthcare bill in full.

Hospital plan

A hospital plan covers treatment and medical costs which arise while the insured is booked into hospital. This is often a defined amount, and in some cases will differ according to the type of illness or surgery required.

Medical aid

A medical aid is essentially an insurance product that gives patients access to the private healthcare system within South Africa. Depending on the type of plan the insured selects it will cover a wide range of benefits from hospital costs, specialist consultations, GP visits, and additional tests and procedures.

Gap cover

Gap Cover provides cover to the insured with a medical aid for a number of events, predominantly the difference between what the specialist charges and what the medical aid covers. It is not uncommon for specialists to charge up to 600% of medical aid rates. Another huge benefit is that gap cover provides coverage for co-payments (known as excess in other insurance lines), non-Designated Service Provider (non-DSP) hospital cover, and sub-limit cover. Only people who have a registered medical aid are able to make use of the benefits of gap cover.

It is important to note that people with health insurance products are not eligible to get gap cover, as gap cover is built on the basis of there being a shortfall between what a specialist charges and what the medical aid pays out. For these products there will not be a contribution from the medical aid, meaning that gap cover will not come into effect.

It is equally important to understand the benefits of both your medical aid and the gap cover option that you are selecting. There are many different gap cover plans designed to provide the ultimate level of healthcare for the insured based on both their medical aid option and affordability.

The critical thing when researching a gap cover provider is that you want to know that they will pay you out for what your plan states. Choose a long-standing, reputable provider who has a track record of being there for its members in their time of need. Often providers advertise their product as being the cheapest option to grab your attention, but that may not necessarily be the best option for the insured, so it’s important to do your research.

Brian Harris, General Manager Operations at Turnberry Management Risk Solutions