What Hospital Plans Do Not Cover
people opt for hospital plans because they simply cannot afford comprehensive cover or they feel that they are
healthy and fit and therefore do not need to pay for expensive comprehensive plans. Hospital plans are designed to
make provision for medical treatment in a hospital, not for the cost of day-to-day medical treatment, dentistry or
Many medical aid schemes say that their hospital plans fully cover hospital treatment but
consumers need to be aware that this is not always the truth. Before choosing a specific plan, it may be
useful to consider the following factors:
- Many hospital plans promise a hundred percent cover for treatment in
hospitals. What they do not point out clearly sometimes is that they will only pay a hundred percent of the
approved medical aid rate. There can be a vast difference between this rate and the actual charges of the
hospital, the doctors and the specialists. In many cases the final bill is as high as four times the approved
medical aid rate.
- Some hospital plans include emergency transport to a treatment
facility, but not all of them. It is important to check.
- Hospital plans are not designed for providing cover for everyday
medical expenses. Some plans offer rudimentary cover for the treatment of certain conditions but the amount of
cover forthese benefits is usually limited.
- Some hospital plans make provision for covering the cost of take-home
medication after hospital treatment but many others do not.
- Most schemes require their members to make use of only those
hospitals, pharmaciesand doctors that are part of their networks of approved service providers. If such
limitations are unacceptable it may be better to look at a different plan.
- Most hospital plans do not provide any cover if a medical emergency
occurs outside the borders of South Africa. In such a case it may be necessary to take out special insurance
that will cover emergencies when traveling abroad.
- In some cases members are able to upgrade from a hospital plan to
another, more comprehensive plan when circumstances change, but some schemes do not offer this option. It is
better to opt for a flexible plan from the word go.
- Many hospital plans have exclusions, meaning that certain treatments
and procedures, even in hospital, are not covered.
- Most medical schemes require their members to obtain approval from
the scheme before admittance to a hospital. If this is not done the member can be held liable for the
- Many medical aids will only pay for a certain time in hospital. They
may, for example, rule that no more than three days in hospital is necessary for a specific procedure and they
will only pay for that time unless a detailed justification is provided by the doctor in charge of the
The fact of the matter is that there is no such thing as a hospital plan,
or any medical aid plan for that matter, that offers unlimited cover. Members must study the terms and conditions
of their hospital plans and they
should make sure that they keep to them when accepting medical treatment. © Medical Aid Plan