This is Part Three of our 2025 Health Insurance Guide.
What is the Illness Hospital Benefit?
This is an insurance product – different from a medical aid – that pays for the hospital stay and treatment for certain health conditions that are not due to an unforeseen accident. So think things like giving birth, cancer, tonsillectomy, stroke, heart attack or burst appendix.
The Illness Hospital Benefit can help pay for costs associated with hospital stays and treatment, but because such procedures are often unpredictable in costs, you should not expect to have comprehensive cover in the event of an illness. Nevertheless, insurers have come up with some very clever and helpful plans that will alleviate some of the stress around hospital admissions.
Remember that the Illness Hospital Benefit is separate to “Accident Cover Benefit“.
Note: not all these benefits are available on all the plans.
Casualty Benefit
Illnesses that require a visit to ER might be sudden shortness of breath, food poisoning, high fever. There are two types of cover for casualty as a result of an illness:
- Requires admission to hospital
- Does not require admission
If there is no admission required, then you will be using a simple “ER accident” benefit. These usually have a per event and per year limits and these limits will apply to “per person” or “per family”. But make sure your ER benefit covers you for illness! Some only cover you for accidents.
Hospitalisation Benefit
Your Illness Benefit should at least partially cover stays and treatment in private hospitals, and possibly procedures in day hospitals too (Example: Affinity Health Hospital Plan).
Cover for illness hospitalisation can range from unlimited to a set limit per day (Example: Affinity Health), or set limit per year or event.
Some plans also pay out a fixed, lump sum for specific procedures, sometimes in addition to a per-day payout. Example, EssentialMed pays R21,200 for a hernia repair.
The value of the benefits is of course related to the premium cost. It is difficult to predict just how expensive surgery or hospital stays can be, so it’s important to make sure your plan matches your risk and your pocket. Speak to your broker about your options.
Sub Acute treatment
If your illness requires a step down facility post treatment, some insurers will include this benefit. (Example: Affinity Health)
ICU Stays
An optional benefit that pays out per day spent in ICU. Limits daily payout and days paid. (Example: EssentialMed)
Dread Disease Benefit
Some plans will include additional cover for dread diseases like cancer, heart attack and stroke. (Example: Affinity Health).
Birth Cover
Plans will often include a pre-set amount for natural and/or C-section delivery. Many hospitals also charge a set fee for private patients, so you will have a good idea of your financial exposure. Expect a 12 month waiting period for this benefit.
Newborns are rarely automatically covered (like they are with medical aid). Some insurers provide specific cover for newborns in the first weeks post-birth. (Example: Oneplan).
Some other possible benefits:
- Post hospital private nursing
- Ambulance transport, repatriation and trauma support.
- Funeral policies and death cover
What next?
In Part Four we discuss Primary Cover in more detail. Read it here.
