total risk administrators (TRA) logo

The difference between medical aid and medical insurance: Which is better?

Toddles listening to doctor

Medical aid and medical insurance are different types of healthcare coverage that can provide financial assistance for medical expenses.

Which one is better depends on many different factors. This includes individual circumstances, such as personal health status, budget, and preference.

This article will help guide you through your options.

What are medical aids?

Medical aid, also known as a medical scheme, is a type of health insurance that health insurance companies offer in South Africa.

Medical aid covers most healthcare services, including hospitalisation, specialist consultations, prescription medication, and chronic disease management. They typically require members to pay a monthly premium and often have co-payments or deductibles that members must pay for certain services.

How does medical insurance work?

Medical insurance, also known as health insurance, is a type of insurance policy that provides coverage for medical expenses such as hospitalisation, doctor consultations, diagnostic tests, and medication.

These plans are typically offered by private insurers, and premiums can vary depending on the level of coverage and deductible chosen.

Medical aid vs Medical insurance

Medical aid may be a better option for individuals with chronic health conditions or those who require frequent medical care, as it typically covers a wider range of services and often has lower out-of-pocket costs for members. However, medical aid can also be more expensive than medical insurance, especially for those who are relatively healthy and do not require frequent medical care.

Medical insurance may be a better option for individuals who are relatively healthy and do not require frequent medical care, as it can provide coverage for unexpected medical expenses. However, medical insurance plans may have more limited coverage compared to medical aids and often require higher out-of-pocket costs for members.

Ultimately, the decision between medical aid and medical insurance depends on individual circumstances and preferences, and it is important to carefully consider the benefits and drawbacks of each before making a decision.

Why consider a medical aid scheme?

Rather have it and not need it than not have it and need it! Private healthcare costs can run into the hundreds of thousands, and having a medical scheme in place (along with gap cover) can save you from falling into financial debt when an emergency happens.

Even if you are the fittest and healthiest person – accidents can happen, and it is important to have a plan in place.

Why is having a medical aid important?

The cost of healthcare in South Africa is incredibly high, and should you find yourself in any kind of accident or medical situation, being a member of a medical scheme could be your saving grace.

Having a medical aid can be a lifesaver for any individual or family when it comes to the financial implications of a medical emergency. What’s great about being a member of a medical scheme is that you can choose a plan to suit your needs.

In order to get the right plan for you and your family, it’s important to do some research and really figure out what costs you can afford for the type of plan that you will need. There are various websites to visit to get comparisons, as well as consultants that you can talk to who can give you the information that you need before you sign up.

Common Medical Aid terms explained:

(View the full list visit here.)

Prescribed Minimum Benefits or PMBs:

Currently, there is a list of 270 medical conditions (including HIV/AIDS, cancer and strokes) and 25 chronic conditions (such as diabetes, asthma and high blood pressure) for which all medical schemes have to provide diagnostic and treatment cover.

Out-of-hospital/day-to-day cover:

These are medical costs that do not involve a stay in hospital. These include visits to your GP or treatment and medicine for colds and other common ailments.

Co-payment:

These are the out-of-pocket payments you would have to make for the shortfall between what your medical aid will cover and what your healthcare provider charges.

Note: Healthcare providers are not obliged to charge medical aid rates, and their fees can be higher than what your scheme will cover, so it’s worthwhile finding out what this difference will be before your consultation. In certain situations, medical schemes will waive the co-payment if you don’t have another treatment option, other treatments haven’t worked, or it’s an emergency.

Pre-authorisation:

This refers to the prior consent in the form of a pre-authorisation number that you require from your medical aid if you are going into the hospital for a scheduled or pre-arranged procedure.

Late-joiner penalty:

In very simple terms, medical aids rely on healthy members to subsidise older and sicker members. Therefore your premiums are higher if you join a scheme at age 35 or older because you’re perceived as being a bigger risk.

Threshold:

This is where your day-to-day medical expenses are paid out of that savings account if you have one with your medical aid plan.

Waiting period:

When you join a medical aid for the first time or haven’t been a member for 90 days, you’ll be subjected to a waiting period before you can start claiming.

Medical Gap Cover Questions & Queries

A Gap Cover plan is what you can also get in order to cover any medical aid in-hospital shortfalls. Having medical aid is the first step, but even then, you might have to cover costs to cover the differences between what a doctor may charge over and above medical aid rates.

If you have any more queries or questions regarding anything related to TRA Gap Cover, you can contact us any time.

Note: All material on this website is provided for your information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this information; instead, readers should consult appropriate health professionals on and matter relating to their health and well-being. The information and opinions expressed here are believed to be accurate, based on the best judgement available to the authors, and readers who fail to consult with appropriate health authorities assume the risk of any injuries. Errors and Omissions Excepted. Terms and Conditions Apply.

Note: All material on this website is provided for your information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this information; instead, readers should consult appropriate health professionals on and matter relating to their health and well-being. The information and opinions expressed here are believed to be accurate, based on the best judgement available to the authors, and readers who fail to consult with appropriate health authorities assume the risk of any injuries. Errors and Omissions Excepted. Terms and Conditions Apply.

OUR LATEST NEWS

6 February 2024News, TRA News

The Best Gap Cover in South Africa: Going The exTRA Mile for their Clients

Gap cover has become an essential safeguard against unforeseen medical expenses for South Africans. With so many options available, understanding

18 January 2024News, TRA News

TRA’s Support for Out-of-Hospital Procedures

Total Risk Administrators (TRA) is committed to offering comprehensive gap cover for various out-of-hospital procedures. The following article expands on

Read More
8 January 2024News, TRA News

TRA’s Gap Cover Exclusion Policy

Policyholders need to understand that having medical aid does not guarantee that your insurer will cover all of your medical

Read More