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Hospital Plan or Comprehensive Scheme?



When looking into medical coverage and the different coverage options that are available, one of the big questions that people often ask is whether to go for a hospital or comprehensive plan. It really comes down to what your healthcare needs are and how much you’re willing to spend. Depending on your needs, some plans will be more suited to you than others.

Here are some important points to keep in mind when you’re weighing up the different options:

1.) Prescribed minimum benefits. Every medical insurance plan has a list of prescribed minimum benefits which includes conditions that members will be covered for, regardless of the option selected. So even if a member of a particular scheme has used up all their benefits for the year, the medical insurance company is still required to pay if the condition is one of the prescribed minimum benefits. By law, every medical scheme needs to provide cover for PMB’s which includes medications. Depending on the plan you’re on, treatment may only be available at certain facilities or designated service providers (DSPs).

2.) Medical coverage providers will also have a list of procedures/conditions that you won’t be covered for called exclusions (cosmetic surgery, removal of tattoos, food supplements and blood pressure monitors, etc.)

3.) It may be more suitable to opt for a hospital plan if you’re young and you don’t have any pre-existing medical conditions. They provide cover in the event of an accident and are generally cheaper than comprehensive plans. Some will also provide cover for specialized procedures such as extraction of wisdom teeth.

4.) Consider your family’s medical history and your personal healthcare needs. If you suffer from a chronic condition and you need to take medication, then a hospital plan may not be the best option for you because you’ll have to pay for the medication.

5.) If you’re older and joining a medical coverage scheme for the first time, you may be required to pay more because you’ll be considered a higher risk.

6.) Most medical insurance providers have a period after you’ve joined when they won’t cover you, which can be anything from 3 months to a year. Be sure to check on this.

7.) Plans will have different coverage rates (Known as the medical fund rate). Be wary of this. Some plans will cover you for 100% or 200% but doctors can charge up to twice this rate, leaving you to pay the difference. Bear in mind however that this is still better than having to pay the entire bill yourself.

In the same way that accreditation bodies oversee service delivery and patient safety standards in hospitals, medical aid providers also have governing bodies.