How medical aids pay your day-to-day claims

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Your day-to-day claims and benefits

Medical aids divide all claims into two main buckets: in-hospital claims and out-of-hospital claims. This article deals with out-of-hospital claims, otherwise known as day-to-day expenses. These are the claims accumulated while you were not admitted in hospital.
The important thing to know: even “hospital-only” plans cover a big chunk of day-to-day claims.

There are 6 ways in which day-to-day expenses can be paid:

  • By the scheme, as a PMB expense
  • By the scheme, from risk
  • By the scheme, from “fund”
  • By you, out of your savings account
  • By scheme, out of your “Above Threshold Benefit”
  • By you, out-of-pocket

Paid as a PMB expense

If the day-to-day claim is for a PMB condition, and if you used the medical scheme’s guidelines and protocols, the full bill will be paid by the scheme, even if you obtained the services out-of-hospital.

This includes claims for diagnosis, treatment and management of over 270 PMB conditions, including 25 chronic conditions (such as asthma). You can see a full list of the conditions here.

Note that this applies even to “hospital-only” plans.

Paid by scheme from risk

If a medical aid pays for a claim out of its “own” funds, it is said it paid it “from risk”. Most claims for in-hospital services are paid from risk, as are the PMB claims described above. But pretty much every medical aid plan offers some other day-to-day benefit that is paid from risk.

These benefits can be substantial. For example, almost all plans offer a mammogram and many plans offer maternity consults. You can see which benefits apply to your plan when you view your plan’s full benefits on our site.

Paid by scheme from a “fund”

Some plans allocate a “day-to-day fund” that you can use for your out-of-hospital expenses. This can be as an addition to a savings account (see below) or can exist on its own. The fund might or might not be affected by PMB claims – this depends on the plan, and is explained in your plan’s benefit page.

The “fund” is different from your savings account (see below). For example, unused portions do not carry over into the following year. Not all plans have a fund.

Because each plan has different rules for how its fund can be used, it is best to review the plan’s rules carefully. You can start by viewing the benefits on, and then confirm with your scheme or broker directly.

Paid from Savings Account

With plans that have a savings facility as part of the day-to-day benefit, you get an annual allowance, known as your savings account. It is funded by a portion of your premiums over the year, although the full amount is available to you in January. Because the savings fund is funded directly by your monthly premium, it is your money.

There is no financial advantage to a savings account: the scheme does not “top up” the account. In addition, a scheme can:

  • limit how much of your savings account can be used to pay for a claim
  • limit how much you can spend per benefit per year out of your savings account
  • limit what benefits you can claim for out of your savings account

The main advantage of having a savings account is that the full year allowance is available for you to spend in January. It also forces you to be disciplined in saving for your day-to-day expenses.

The disadvantage of a savings account is that claims are not often paid at the rate you expect, and savings are often depleted sooner than anticipated. Also, sometimes claims taht should be paid by the scheme as a PMB (see above) are paid from the savings account due to admin errors, so you need to monitor your claims very carefully, always.

Paid from “Above Threshold Benefit” (ATB):

This is offered by the more expensive comprehensive medical aid plans, and can be a bit tricky to understand. Essentially, it works like this: when your day-to-day expenses have reached a certain “threshold”, all further day-to-day expenses are covered by the scheme.

Your day-to-day expenses that accumulate to the threshold can be paid from your savings account or out-of-pocket (known as the self payment gap). Once all your claims add up to the threshold, the ATB kicks in.

The ATB can be limited or unlimited, depending on the plan. Even with an “unlimited” ATB, there can still be sub-limits for certain services.

Paid out-of-pocket

If a claim cannot be paid by any of the above methods, it is paid by you out of pocket.

Sometimes, a doctor or health professional will request that you pay out-of-pocket even if you have a fund or a savings account. You then need to claim back from your medical aid.

What next?

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