Updated 24 October 2013

Weigh up your medical cover

Now’s the time to weigh up your medical cover, consider your stage of life, your state of health and the state of your pocket and choose the right medical scheme for you.


Now’s the time to weigh up your medical cover, consider your stage of life, your state of health and the state of your pocket .

Critical period
Medical schemes review their benefits annually and the end of the year is the time when schemes encourage their members to re-evaluate their medical cover and decide whether to upgrade or downgrade to a different option, change schemes altogether or stick with their existing cover.

Recession versus requirement
In tough economic times when money is tight, people often look at ways they can reduce their monthly expenses to weather the storm. Says Dr James Arens, Clinical Operations Executive of Pro Sano Medical Scheme, "If you’re looking to cut back on your costs, consider downscaling to a cheaper medical aid option rather than cancelling your medical insurance altogether. The lower-cost option will still cover you in an emergency, for example if you need to be hospitalised after an accident."

Consider the alternative if you are tempted to cancel your medical insurance altogether, says Arens.

"Medical aid covers your medical expenses if you get ill or need medical treatment after an accident or injury, for example. Those without medical cover must rely on state health care facilities, or end up funding their own health care costs. Most of us would quickly run out of funds if it came to paying for prolonged hospitalisation, or expensive tests and procedures."

Shop around
There is a broad range of medical aid options on offer, from low-cost hospital plans which cover hospital care only, to fully comprehensive cover which insures you against any medical eventuality. A single person in their early twenties might choose a cheaper hospital plan option, while a couple expecting a baby or a family with young children might choose a more comprehensive plan that covers doctor’s and dentists’ visits, as well as necessary medication.

Many plans also allow for the main member to include additional dependants on their plan, such as an elderly parent or a life partner.

Choose a scheme to suit your lifestyle and your pocket
In order to choose the most appropriate option for your family, it’s important to understand your own healthcare needs. Investigate the different options thoroughly and choose the best and most cost-effective medical aid cover to suit your family’s changing lifestyle and healthcare needs:

Step 1: Know your health risk profile
Obtain a comprehensive health profile of all the members of the family covered by the scheme, including their ages, and health risks. If necessary, ask your GP or physician to assist you by taking a detailed family history and discussing specific conditions and health risks relating to your family.

Step 2: Scrutinise the benefit structure of your scheme
Once you have a good idea of your health risks, you can identify which benefits structure would best suit your needs. For this you may need the help of a broker that is familiar with a range of medical scheme benefits. Ask the following questions:

  • Are hospitalisation costs funded 100% or are there co-payments?
  • Are serious and expensive medical conditions of your dependants and yourself funded by the scheme?

Step 3: Check out the financial soundness of the scheme
The schemes financial stability can be ascertained by ensuring that the solvency levels are above 25%. Obtain a Global Credits Ratings on the scheme; which is a measure of the scheme’s claims-paying ability. The claims ratio also gives a good measure of the scheme’s operational efficiency.

Step 4: Ensure affordability
While it is essential that one is comprehensively covered for a current and potential health risk, the reality is that affordability will ultimately determine what medical aid option you decide on. Draw up a realistic family expenditure budget to help ascertain how much you can spend on health insurance.

"In this day and age, everybody should have some form of medical cover," says Dr Arens. "The key is to choose a scheme and a health care option to suit your stage of life, your state of health, as well as your pocket."

(Dr James Arens, Clinical Operations Executive Pro Sano, November 2009)


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