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How medical aids work

A brief introduction to how medical aids work, the different types of plans, and their obligation to cover out-of-hospital expenses for certain conditions, regardless of plan type.

How to use this site

We know the medical aid industry is complicated, and the information presented on this site...

All about PMBs, and how schemes have to pay for them

PMBs are 270 conditions that schemes have to cover without requiring co-payments or savings from you, even if the treatment is provided out-of-hospital. This applies to every plan.

From our blog:

Pregnancy cover if you don’t have medical aid

Pregnancy is considered a medical condition, and as such is subject to waiting periods when you join/change medical aid schemes. Waiting Periods If you have not had medical aid for more than 90 days and are pregnant, a scheme can impose a 12 month waiting period on your pregnancy, meaning that...
Affordable Medical Aid

Help us crowdsource information about the Late Joiner Penalty

The Medical Aid Bible team has been listening to some of our wonderful site users, and we have heard horror stories about how some of you are being overcharged for the Late Joiner Penalty. This enticed us to investigate how each scheme handles the penalty. We found some big irregularities.

Our complaint against Bestmed re late joiner penalty

We investigated all the open medical schemes, and discovered some discrepancies in how some schemes are representing the late joiner penalties (LJP). Bestmed was one of those schemes.

Our complaint against Commed re late joiner penalty

We investigated all the open medical schemes, and discovered some discrepancies in how some schemes are representing the late joiner penalties (LJP). Commed was one of those schemes.

Our complaint against Genesis re late joiner penalty

We investigated all the open medical schemes, and discovered some discrepancies in how some schemes are representing the late joiner penalties (LJP). Genesis was one of those schemes.

Is your late joiner penalty worked out correctly?

We have found that some schemes and brokers misrepresent or miscalculate how the late joiner penalty is applied. We have laid three complaints with the Council of Medical Schemes. If you are paying a late joiner penalty, you can use the information on this page to determine if you are paying the correct penalty.

Should a medical aid scheme pay for experimental treatment?

Should medical schemes fund experimental treatments if they are a member's only option for survival?

Medical Aid FAQs:

How medical aids work

A brief introduction to how medical aids work, the different types of plans, and their obligation to cover out-of-hospital expenses for certain conditions, regardless of plan type.

Will I have to pay a Late Joiner Penalty?

What is it? A late joiner penalty is a permanent penalty, added as a percentage of the base premium (not the savings portion). It is meant to dissuade or penalise people from not belonging to a medical aid in their youth, when they are presumably healthy, and joining only when...

Do I need a medical aid broker?

No, you can apply to become a member of any medical aid directly to the scheme. Some schemes don't work with medical aid brokers at all. How much does a medical aid broker cost? A broker does not cost you, the member, anything. Your premiums do not increase if...

How do I complain about a medical aid issue?

Start by speaking to your scheme. Put all your communication in writing. Some schemes will have an appointed person who deals with escalated queries or complaints. If your complaint is not resolved to your satisfaction, ask your scheme if the matter can be escalated. You can also contact the...

When can I change my medical aid plan?

Determining when you can change your medical plan depends on whether you want to stay with the same scheme or not.

What are “Waiting periods”?

Waiting periods are imposed by the medical aid scheme on new members, based on their medical history. The waiting periods can also be applied to Prescribed Minimum Benefits (PMBs).

Can I be refused membership of a Medical Aid Scheme?

No. A medical scheme is generally not allowed to refuse you membership, including on the grounds of past-ill health, or you being a high risk. A scheme, can, however impose waiting periods. A scheme is also not allowed to charge you a different (higher) premium because of your past...

How do I change my medical aid plan?

A quick guide to how you can change your medical aid plan, including the resignation procedure, and things to look out for, such as imposed waiting periods from your new scheme

All the jargon explained

DSP A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition (see below for definition of PMBs). (source: Council for Medical Schemes) Extended Benefit This is “extra” coverage, usually for...