Medical aid is often one of the first areas of spending to be cut when times are tough, especially if you’re young, healthy and fit. But no one knows when illness will strike, and cover could help save your life without bankrupting your family. 

Cervical Cancer Awareness Month seems an apt time to remind ourselves of the importance of medical aid and gap cover. Cervical cancer is the second most common cancer in south African women and can affect women at any age. It is usually diagnosed from the results of an often uncomfortable, and sometimes embarrassing, pap smear. 

A few years ago, I met a 28-year-old member with stage one cervical cancer. She’d been for a routine pap smear in which abnormal cells were detected. Desperate to have children, she underwent surgery to make it possible for her to have a baby. Luckily her medical aid covered her condition as a prescribed minimum benefit (PMB, one of a number of selected conditions that all schemes must cover) so she was able to afford the treatment. 

When she became pregnant a few years later, her selected gynaecologist charged above the scheme rate. Having gap cover in place allowed her to use the provider of her choice as in-hospital shortfalls and specialist consultations were covered too. 

How do I choose a medical aid?

1. Identify what your medical needs are. Consider factors such as the requirement of cover for a chronic condition and whether you want the freedom to see any provider or hospital facility of your choice. Having the flexibility to choose any doctor, specialist or hospital often comes at a price; it is sometimes more affordable to use the scheme’s network providers for your treatment. 

2. Examine the restrictions applicable. Most medical schemes have contracted with certain providers and hospital facilities to offer more reasonably priced member benefits. This may save you from out-of-pocket spending and penalties imposed by using non-network providers. 

It’s also important to understand that chronic conditions may also be restricted in this way. While all schemes must cover chronic conditions as per the Chronic Disease List (CDL), schemes are allowed to put in place Medicine Formularies, Designated Service Providers (DSP) and a Basket of Care for tests and procedures required by the member. This means that a member must use the medication as prescribed by the scheme’s formulary and/or DSPs, otherwise treatment may be subject to co-payments.

3. Understand what is and isn’t covered. While cervical cancer is a PMB, skin cancer, for example, is not. Some plans will not cover treatment for this at all and on others, it would be payable from your day-to-day benefit or Medical Savings Account (MSA). This is why it is critical to select a plan type that suits the needs of the individual or family. Selecting a plan based on cost alone could sacrifice benefits which may have unwanted health consequences further down the line. 

4. Find out what the scheme rate is and how that compares to the cost of treatment. Medical schemes pay providers at scheme rates and most members are under the impression that 100% of scheme rate covers 100% of the cost incurred. This is where gap cover can help by providing for shortfalls in hospital treatments and certain out of hospital expenditure dependant on the plan type selected. 

Medical aid, like any insurance, is often a grudge purchase. But as my young member discovered, it can make a real difference to your pocket if the unexpected happens. Your financial adviser can help you assess your options to ensure you choose the right cover for your family.