Types of Health Insurance:
Health Insurance is not medical aid.
Broadly speaking, health insurance can help you in three scenarios:
- with your day to day expenses (Primary Care Benefit)
- in case of an injury due to an accident (falling off a ladder, car accident) (Accident Benefit)
- in case of illness (heart attack, kidney stones, tonsillectomy). Childbirth falls under this category too. (Illness Benefit)
Health insurance plans come in all sorts of configurations, and you can choose to be covered for any combination of the above three scenarios. Often, an insurer will allow you to custom-make your own plan by stacking a number of optional benefits together. Episodic is a good example of this.
What is Primary Care?
This is cover for day to day benefits, like seeing your GP or getting an X-ray. Depending on your plan, you will either pay these costs upfront and be reimbursed later, or your insurer will have an arrangement with the service provider. See more detail here.
Tip: Oneplan tops up a dedicated debit card that you can then use to pay for the services
What is Accident Cover?
This is for all unplanned events that occur due to an external source, and that require medical attention. (See a detailed definition in next sub-heading.) Accident cover is usually separated into three levels:
- Casualty only ie no admission to hospital is covered
- Stabilisation only. You can be admitted to hospital until you are stabilised. You can then be discharged or moved to a State facility.
- Treatment. You are treated in private hospital until discharged, or until cover runs out.
Your plan will determine what type of care you get for each of these scenarios. See more detail here.
If you have medical aid, you likely do not need accident cover. Your medical aid has to pay the claims for most accidents.
What qualifies as an Accident?
It’s a sudden and unexpected event, that occurs at an identifiable time and place, and that requires immediate medical treatment due to physical injury caused by physical impact, and that is independent of illness, disease or other bodily malfunction.
What is Illness Cover?
“Illnesses” are medical events that are not caused by an external source. Examples include a stroke, hernia or cancer. Illness cover is broadly separated into three levels:
- Casualty only
- Hospital Treatment, for conditions that require you to be admitted to hospital
- Extra cover for dread diseases (cancer, heart attack, stroke)
Every plan will have their own spin on these, with specific limits and conditions, and different combinations of benefits. See more detail here.
If you have medical aid, you likely do not need illness cover. Your medical aid has to pay the claims for most serious illnesses, like stroke and cancer. Speak to your broker for specific details.
Pre-existing Conditions:
Just like with any other healthcare cover products, you will likely have a waiting period for any pre-existing condition, usually 12 months.
Some plans also have general waiting periods when you first join, although those can sometimes be waived for claims arising due to an accident.
There are also condition-specific waiting periods. For example, there is usually a 12 month waiting period before maternity benefits are available.
How much does it cost?
Plans start at about R150 per person, and go up to R1,500+.
Policies are usually quoted per person, and there are different rates for main members, adult dependants and children.
Children over the age of 21 are usually considered to be adult dependents, although some insurers like Episodic charge child rates up to the age of 26 if child is a full time student.
Note that unlike medical aid, health insurance providers can limit cover to a certain maximum age, or charge a higher premium for seniors. Some insurers (Example: Unity Health) will waive the senior penalty if you can prove continuous membership of medical aid for the past 15 years.
Can you have insurance and medical aid at same time?
Yes. This makes most sense for primary care cover, where you can complement your “hospital” medical aid with day-to-day cover for GPs, x-rays and medications as well as cover for all ER events.
Note: Some plans do not allow you to be on the plan and medical aid. (Example: Discovery’s Flexicare).
How do claims get paid
For day-to-day costs, you can either pay out of pocket and be reimbursed later, or you can use a network provider with a payment arrangement with your insurer. For hospital admissions, you need pre-authorisation which will give you a GOP (guarantee of payment) which most hospitals honour. Alternatively, any cash lump sums will be paid directly to you.
Tip: Oneplan tops up a dedicated debit card that you can then use to pay for the services
What are group policies?
Group policies can be taken out by companies to provide their employees with healthcare cover as an added benefit to their pay package. They work out cheaper than individual policies, and can often be negotiated on the finer details. (Example: Kaelo)
You can also take out cover for your domestic staff or other third parties.
