05/10/2021
You and your medical aid – Orthopedic perspective:
It is that time of year that you should reconsider the option of your medical aid. In November you will be allowed to change the option for 2022.
You might also be in the market for a Medical aid.
I have a few thoughts on these as I often see patients that have problems with the option or the medical aid that they are on.
Co-payments for Specialized Radiology:
As modern medicine has evolved, specialists very often require Magnetic Resonance Imaging (MRI) before surgery. Most medical aids will allow more than one MRI per member or family, but will insist on a co-payment to be made. Be aware of these co-payments and the cost. If you have been lucky you still have some money in the savings plan, but don’t bank on it.
Co-payments for procedures that require laparoscopies or arthroscopies:
Most medical aids will require that you pay a co-payment for surgery done with “the camera” or minimal invasive surgery. These co-payments can be prohibitively expensive. One relatively common medical aid in the market has a hefty R 10 000 co-payment for any arthroscopy (camera surgery of a joint e.g. knee or shoulder).
As a general rule of thumb, Gap Cover will not reimburse you for co-payments.
Selected Hospital Network:
Although you can save R 200 – R 300 by choosing an option that would not allow admission to all hospitals but a select network, it is not a good idea.
We have very few private hospitals in Mpumalanga. The Life Healthcare group has only one hospital, which is situated in Middelburg. By limiting your options you might not be able to source the proper expert care that you need, and it might be in another town, rather than your own. This will require you to travel.
We have very few specialists that “super specialize”, e.g. Physicians that specialize in gastro-enterology or, Orthopaedic Surgeons specializing in Shoulder surgery. The super specialist that your need, might not work in the hospital that is on the selective list of your medical aid.
I once tried to refer a patient to one of the top hand surgeons in the country, only to find out that she was not on the patient’s list of options, despite practicing at one of the largest hospitals in Gauteng. This can be to the detriment of the quality of your care.
Exclusions by the medical aid:
As ridiculous at it seems (to us as surgeons), there are medical aids that will exclude patients from having a joint replacement (for instance). This might seem reasonable if you are below the age of 50 years. Once you are in the age group where “wear and tear” or arthrosis becomes an issue, it is the worst possible option.
Watch out for cheap plans that just cover “Prescribed minimum benefits” (PMBs). Please don’t even consider these as it covers an extremely small possible of conditions that can befall you. As far as orthopedics are concerned it will only cover you if you fracture bigger bones or dislocate bigger joints. It might not even cover you for the traumatic tear of some of the tendons.
Medical Insurance:
Don’t take out medical insurance. Most of these are the same as the medical aids that just cover PMBs. It is just not a good product. Some might even require you to pay upfront and reimburse you afterwards. In the South African market these are not up to standard.
Choose your broker with care / don’t trust HR to assist – research yourself:
Your broker needs to have intimate knowledge of medical care and what is required in the successful treatment of a patient. The broker needs to understand what risks you carry in terms of health and required healthcare.
Choosing the correct medical aid and option is much more than just going through the monthly contributions and what money you have available to pay the debit order every month. Each option within a medical aid has its own nuances. Although you might be able to afford a specific option doesn’t necessarily imply that it is the right one for you.
Gap cover:
Seriously consider taking gap cover, especially if you don’t have spare money that can be used to pay outstanding bills. Once again, you have to understand what exactly is being covered as most gap cover products just pay shortfalls after hospital admission. They also have terms and conditions that you must understand.
These are my thoughts at the moment. If you have more questions, please ask? I am not a fundi on all medical aids, and my experiences relate to orthopaedic care.
Gone are the days that you can just trust the broker or the person at HR to advise you. You have to have intimate knowledge of what benefits you are paying for every month.
