Medical aid plans offering unlimited benefits are a popular choice because they cater for most eventualities. The term “unlimited benefits” is used often in the marketing of medical aid schemes because it gives the impression of complete cover regardless the specific plan’s stipulations. But what exactly does it mean when a medical aid scheme includes unlimited benefits?    

In short, medical aid options that include unlimited benefits, whether it is for hospitalisation, ante-natal consultations or other medical treatments, allow you to make an unlimited number of claims according to the restrictions set out in your particular scheme. For example, if your option includes unlimited hospital cover and you fall victim to a car accident, you will be covered for all hospitalisation procedures regardless of the total costs involved. You may still, however, be liable to contribute towards each operation, depending on the specifics of your policy.

By contrast, instead of offering unlimited benefits, some medical aid providers offer schemes with an annual limit, meaning that they will only allow you to claim until you reach your capped amount. In a situation where you require medical attention but have exceeded your cap, you would be required to make any additional payments for yourself. Plans with unlimited benefits do not have such limitations.

In the event of an unexpected accident, you could require several operations which may well end up being incredibly costly. Emergency medical care can often cost in excess of R100 000. Should you require multiple operations in a short space of time, extensive medical care for your entire family or if there are complications from surgery, the bills can mount up quickly. Your time in hospital should be focused on recovering, not worrying about how you are going to pay your medical bills.

Here at Selfmed, we pride ourselves on the fact that every one of our medical aid plans includes unlimited benefits for hospitalisation. With any Selfmed medical aid plan, you can rest assured that you are covered throughout the entire year and up to any amount, regardless of previous claims.

It’s often incorrectly assumed that if your medical aid scheme offers you unlimited benefits – on your hospital plan for example - you will not be required to contribute financially towards your treatment and time spent in hospital in any way. This is, however, not always the case.

In order to understand what unlimited benefits mean for you as an individual, you need to take a look at your actual medical aid plan to see what percentage of your treatment you are covered for. Be careful not to assume that because your medical aid plan states that you are covered for 100% of the medical scheme rate (MSR) that your entire bill is covered. Most medical aid providers generally base their MSR on a standardised pricing system called the National Reference Price List (NRPL) which dictates the expected cost of medical procedures.

Medical practitioners, however, are not obliged to charge these suggested rates, which is why you may end up contributing financially to your treatment even though your medical aid cover offers “unlimited benefits”. If your medical aid scheme pays 100% of NRPL and your doctor charges more, you will be required to pay the difference.

Different options offer varying levels of cover. Your monthly payment largely dictates how comprehensive your scheme is. As part of your cover, your medical aid provider will pay a percentage of your hospitalisation and medical fees. Many schemes pay 100% of the NRPL, which can be sufficient of you are treated by a doctor who charges NRPL rates, and some pay more than 100%, which gives you a wider choice regarding which doctors and hospitals you use.

In certain instances, you may be expected to contribute financially because a co-payment clause is included in your medical aid plan. A co-payment is a flat amount that you are required to pay for a particular procedure. Some medical aid schemes require their members to pay a fixed amount for specific treatments even if they are covered for more than the treatment costs. For example, Selfmed’s MEDXXI plan covers you for all in-hospital services and treatments at a maximum rate of 100%, with co-payments applying to procedures such as hip replacements. 

Even though a specific policy may have unlimited benefits, it is popular for medical aid providers to implement managed care intervention in order to ensure that funds are not wasted unnecessarily. These measures are not taken to deny benefits or prevent payment, but rather are intended to ensure that members are receiving the correct level of treatment at an appropriate price. An emphasis is also often placed on preventative care and post-treatment care in order to reduce the number of redundant treatments that put a strain on medical resources.