Medical Aid Frequently Asked Questions

Browse our Frequently Asked Questions section to find out more about medical aids and how to gain maximum benefit out of your personal or family medical aid plan. For tips on how to choose an appropriate option, you may wish to have a look at our case studies.

General

Medical aid and medical insurance are two very distinct types of cover. Medical aid schemes are governed by the Council for Medical Schemes, while medical insurance is governed by either the Long Term Insurance Act or the Short Term Insurance Act.

Medical aid schemes pay out according to a Medical Scheme Rate (MSR), which differs from scheme to scheme, and which also cover a range of Prescribed Minimum Benefits (PMBs). Medical insurance pays out a set rate for each day that a policyholder is in hospital (usually starting only after 2-3 days of hospitalisation), and it is up to the policyholder to decide how to spend the money (i.e: on hospital expenses, or on expenses incurred whilst in hospital, etc.). Most medical insurance schemes are unlikely to cover PMBs.

Yes, providing they can pay the required monthly premiums.

An open medical aid simply means that the scheme is open to the general public. In other words, anybody can become a member of an open medical aid.
Restricted medical aids are not open to the general public. You have to be working a certain sector of industry, have specific academic qualifications or belong to certain trade union or professional association in order to belong to a restricted medical aid.

These are out-of-hospital benefits, which differ greatly from scheme to scheme and from option to option. The bigger your contribution, generally the bigger your cover. These benefits can cover things such as GP visits, prescription medication, dental treatment and visits to the optician.

Gap cover is a form of short-term insurance that covers potential shortfalls between the cost of medical procedures in hospital and the percentage that your medical aid pays towards these costs. For example, some medical practitioners charge up to 400% of MSR rate. If your medical aid only covers 100% of MSR rate, then a shortfall of 300% will be payable by you. Gap cover will cover this outstanding amount. Although gap cover does not cover out-of-hospital procedures, it does cover certain listed procedures performed on an out-patient basis.

Generally, hospital plans are the most affordable types of medical aid, as they do not offer any day-to-day benefits. But bear in mind that the most affordable medical aid plan may not be the most appropriate one for you. In most cases, hospital plans are ideal for young, healthy members who do not have any dependants, and whose medical requirements are minimal. However, members with young children (who may require frequent paediatric check ups, vaccinations, medication, etc.), as well as individuals with chronic ailments or medical conditions may find it more affordable to take out a medical aid plan that also offers day-to-day benefits.

No person may belong to more than one medical aid at any given time, and intentionally belonging to more than one medical aid is considered to be a form of fraud and, by law, is not allowed.

Yes. A medical scheme has the right to terminate your membership if, for example, you fail to pay your contributions, or you do not fully disclose certain information on application for membership to the scheme. A closed scheme could also terminate your membership should your employment be terminated, or if you were retrenched.

Choosing a medical aid plan

Yes. We offer a hospital plan (the MEDXII), as well as comprehensive medical aid plans: Selfmed Selfsure; Selfmed 80% and MED Elite. We also have two network options: SelfNET and SelfNET Essential (private network hospital option). Please visit our Medical Aid Plans page for more information about each of these plans.

Choosing the right South African medical aid scheme and plan is crucial. For starters, you should be sure that the scheme you’re considering is legally registered and financially stable.

You can verify your medical aid scheme’s accreditation on the website of the Council for Medical Schemes.

Consulting your local doctor or closest hospital accountant will also give you an indication of their payment record and how swiftly they process medical claims.

Avoid medical aid schemes that take months to process claims, as you may be expected to foot the bills in the interim. Be sure to read all documentation carefully, making notes of exclusions, rules as well as the conditions pertaining to benefits and hospital cover.

Also find out which chronic medical conditions are covered by the scheme and whether you’ll have to make any monthly contributions.

If you feel somewhat overwhelmed by all the medical aid options, it may be a good idea to consult an independent medical aid broker. (S)he will be able to give you a good idea of what you should be looking for, as well as the potential pitfalls.

Some medical aids refer to their plans as ‘Platinum’, ‘Gold’ and ‘Silver’ (and so forth), depending on the level of benefits of each. Although we do not use these terms to describe our plans, we have a variety of plans that are priced according to the benefits offered. We have the Selfmed 80%, our most comprehensive (and thus ‘Platinum’) plan; the Selfmed Selfsure plan, our ‘Gold’ cover, and our MED Elite plan – our ‘Silver’ plan, which also covers chronic medication. We also consider our hospital plan – the Selfmed MEDXXI – as ‘Gold’ cover, as it offers a high level of hospital cover at an affordable rate.

Benefits

No*. Selfmed is one of the few South African medical aid schemes that allows its members to decide which medical practioner they wish to visit. However, when it comes to providing medication, we do have a list of Designated Service Providers (DSPs), who are our preferred suppliers in terms of providing treatment and care for PMB conditions.

*This does not apply to the SelfNET option which is a Networked option that necessitates the utilisation of Medical Practitioners within the CareCross Network.

Yes we do. One of our friendly consultant would be happy to take you through our product range and explain our chronic medication benefits.

If PMB-related services are rendered by state hospitals or Designated Service Providers (DSPs), no restrictions, exclusions, co-payments or waiting periods may be applied. However, in cases where the services have been voluntarily obtained from non-DSP service providers, then co-payments or waiting periods may apply.

Yes, some of our plans do cover certain dental and optical procedures. One of our consultants would be happy to explain the benefits offered and clarify any questions you might have.

No. By law, no medical scheme may give any bonuses, refunds or rebates of any kind to its members, except in the instance where there is a savings portion owing to the member on termination of membership.

Medical Aid Claims

All claims must be submitted within four months from the end of the month in which the service was rendered. Any accounts not submitted within this time period will not be paid.

Depending on the plan you’re on or the healthcare provider you use, your medical aid plan may not cover your entire medical expense. In this case, you may be responsible for a co-payment, which is the amount that you must pay from your own pocket for a particular treatment or procedure as determined by your medical aid scheme.

In most instances, the service provider will submit the claim on your behalf, and provide you with a copy of the claim. In some cases, you will be responsible for submitting the claim yourself. Note, however, that you are responsible for all claims, and that it is up to you to ensure that all claims are submitted to us – whether by you or by your service provider.

If you received a discount on a medical account, you will only be entitled to receive the lower benefit amount (the full amount less the discount). For example, if you receive a 10% discount on a bill of R500, and we cover the full cost, we will reimburse you an amount of R450 (R500 – R50).

No. Benefits are not allowed in respect of foreign claims, except in the case of claims originating in Namibia. Note that Namibian claims will be refunded (when applicable) in South African rands.

Yes, except in the case of an emergency, where pre-authorisation must be obtained within 2 days of receiving treatment in order for the account to be settled.

Medical Aid Exclusions & waiting periods

Yes, you can. However, you may be subject to a 12 month condition-specific waiting period, in respect of these pre-existing conditions. Each member’s profile is considered individually before waiting periods are applied (where applicable), so it’s important to speak to your medical aid scheme directly.

For example, members with a pre-existing condition who have never belonged to a medical scheme, or who have not belonged to a medical aid scheme for 90 or more days prior to joining Selfmed, or who have belonged to a previous medical aid scheme for less than 2 years, may be subject to these waiting periods.

Dependants

Yes, you can. Simply complete an amendment form, which you can download from our website or obtain directly from us.

Yes. The life partner of the principal member, (also known as common-law husband or wife) is entitled to be registered on their medical aid plan.

Yes you can. However, the child will need to be registered as the principal member of the plan, and will thus pay the same rates as an adult principal member. If, however, you choose to take out medical cover for yourself and add your children as dependants, you’ll pay the contribution of a principal member, but your children will pay a much lower rate than you.

Yes, provided that you are financially responsible for them. We may require proof that your parent(s) is/are financially dependent on you, and you will also be liable for additional contributions required to cover their membership. Note that principle members may only add their parents to their plan, and not their parents-in-law.

Yes, provided that the contributions continue to be paid as before. Dependants may opt to terminate the cover if they so wish, but they must inform the Scheme.

Yes. The MEDXXI provides cover for gastroscopies, colonoscopies and tonsillectomies performed in doctors’ rooms. This means that you’ll be covered for these procedures even if you aren’t admitted to hospital. It also offers cover for CT scans and MRIs both in- and out- of hospital. In both instances, co-payments may apply, and pre-authorisation may be required.

No. Children must be on the same plan as their parent(s)/guardian(s). However, if the whole family is on a more costly plan because one person has a chronic illness or special medical need, consider putting family members on different plans in order to reduce your overall medical aid costs. For example, if one parent has a chronic illness, consider putting the other parent and the children on a simpler, more affordable plan.

Yes, cover will continue uninterrupted, provided that contributions continued to be paid each month.

Assess your medical needs by consulting a medical aid broker, or contact a number of respected South African medical schemes independently. Choose a plan that suits your needs; if you’re healthy and not prone to sickness, it may be a good idea to get a medical aid plan that features low day-to-day benefits, but substantial hospital coverage.

This will stand you in good stead in the case of a car accident, for example. Always read the small print regarding benefits, thresholds and conditions for cover.

You are still covered for treatment until the last day of your notice period.

Medical Aid Contributions

Companies are not required by law to contribute to their employees’ medical aid costs. However, some companies choose to do so. You will need to check with your HR department to find out whether your contributions or a percentage thereof are covered by your employer. Some companies may require employees to join a specific medical aid scheme or plan if they wish to enjoy this benefit.

It could be. However, the medical aid scheme must provide written notice to the employer and/or the member (if they are two separate parties), to inform them that the contributions are not up to date, and that cover may be cancelled if the contributions are not paid in full. Failure to pay contributions will result in termination of membership.

If you are a member of a closed scheme, then your membership will be terminated if you are retrenched or made redundant. However, it will remain in place if you retire. If you are a member of an open scheme, your membership will not be terminated if you continue to pay your contributions in full.

Medical Aid and Pregnancy

The maternity benefits offered by Selfmed differ from plan to plan. All our plans (including our hospital plans) cover ante-natal classes up to R1 500 and generous maternity benefits, including provisions for home birth. Unlimited maternity visits are available on certain plans. Compare medical aid plans to see the various benefits offered by each.

Yes, you can. However, certain waiting periods could apply if you were already pregnant when joining the scheme.

Medical Aid and the Road Accident Fund (RAF)

Read more about road accident fund claims, and also about your obligations as a medical aid member here (Arrive Alive website).

Hospital Plan FAQs

A medical aid hospital plan covers in-hospital treatment (both pre-authorised and emergency), but no cover for day-to-day medical expenses (such as doctors’, dentists’ or specialists’ appointments), medication, or out-of-hospital treatment. Hospital plans do offer PMB cover, as this is required by law.

The nature of a hospital plan is to cover in-hospital treatment, but not day-to-day treatment. As such, Selfmed’s hospital plan (MEDXXI) provides unlimited hospital cover at private hospitals throughout South Africa. By law, the plan also has to provide cover for 26 PMB conditions. MEDXXI also covers Ante-natal Classes and Foetal Scans are further subject to a joint limit of R1,500.00 per year; certain clinical procedures performed in doctors’ rooms (such as gastroscopy, colonoscopy); unlimited MRI and CT scans in- and out- of hospital, and benefits for non-elective maxillofacial and oral surgery.

Yes. The Selfmed MedXXI plan offers out of hospital benefits for ante-natal classes and foetal scans subject to a combined limit of R1600 per family per year – in addition to its hospital benefits.