13/01/2026
Article:
Adriaan Schoeman, DIrector at Medicalaid.com
Parents who want the best for their families when it comes to their health will ensure they follow a healthy lifestyle, go for regular check-ups, and have access to reputable medical professionals when problems arise. However, the complexity of South Africa’s healthcare industry makes it difficult to know where to start in funding a family’s
“Unfortunately, with medical costs rising at a faster pace than the overall consumer inflation rate, the healthcare funding industry is battling to contain costs for consumers. However, some providers – medical aid schemes and insurance companies – are doing better than others at providing healthcare benefits efficiently and cost-effectively,” he says.
There are essentially three routes open to you, which are not mutually exclusive, meaning you can use a combination of them. You can:
Rely on state health facilities.
Take out health insurance to partially cover private medical costs.
Belong to a medical aid scheme to partially or comprehensively cover private medical costs.
“Generally, the more you can afford, the better quality healthcare you will be able to access,” Schoeman says, “but there are ways to optimise what you receive against what you pay.”
State health facilities
The state healthcare system services the bulk of the population, and unfortunately quality and accessibility often leave a lot to be desired, Schoeman says. However there are pockets of quality at state hospitals, depending on where you live. “You may want to explore your local state facilities as part of an overall healthcare plan for your family,” he says.
Health insurance
Insurance companies offer policies that cover hospitalisation and certain day-to-day benefits with a predetermined amount paid for each day in hospital or each insured event. Depending on the policy, it may cover medical emergencies, hospitalisation at a fixed rate per day in hospital, and primary healthcare, such as GP consultations, prescribed medication, basic dentistry and optometry at designated service providers. Note that the predetermined payout is unrelated to the actual cost of the medical treatment, Schoeman says.
Depending on pre-existing chronic and other medical conditions, age, and family size, premiums differ between individual clients. Also note that premiums can increase when you claim and that an insurer may decline cover if you are older or in bad health.
Because they are more affordable than medical aid plans, these policies are becoming more popular among employers wanting to offer their workers basic medical cover as part of their employee benefits.
Health insurers also offer gap cover policies, taken out in conjunction with medical aid membership, which cover the difference between what medical professionals charge and what a scheme pays out.
Medical aid
Unlike health insurers, medical aid schemes are governed by a separate Act of Parliament, the Medical Schemes Act, which protects consumers from measures employed by insurance companies to manage risk. There are two types of schemes: open schemes are open to all, while closed schemes are restricted to certain worker groups.
Importantly, a scheme cannot refuse you membership, even if you are sick and/or old. However, you may be subject to a waiting period (a fixed starting period of, for example, six months, during which it will not cover non-emergency procedures) and higher premiums in the form of late-joiner penalties if you have not had medical aid cover previously or have let it lapse. Further, a scheme cannot arbitrarily cancel your cover if you are deemed high-risk.
Schemes must provide full cover for medical emergencies and a list of life-threatening conditions, known as the prescribed minimum benefits (PMBs), even on their lowest plans. However, the scheme may insist that you use a provider that belongs to its designated provider network.
Medical aid plans, known as options, range from hospital plans, which only cover hospital admissions, to comprehensive plans that cover most medical expenses up to certain limits. Many plans also include a medical savings account, funded by part of your premium, which covers day-to-day expenses.
Schoeman says the range of plans offered by medical aid schemes is extremely wide, and choosing one that suits your family’s needs can be a mind-numbing exercise. “A medical scheme broker can help in this regard.
📧 bianca@nexusifp.co.za
Independent Healthcare Adviser
