The 26 diseases that every South African medical scheme has to cover by law

 ·25 May 2018

With the introduction of new regulations in April 2017, the health insurance landscape significantly broadened South Africans’ access to medical cover.

Historically, health insurance providers could refuse to cover individuals based on a number of factors such as age, disability or health status.

The introduction of the Demarcation Regulations, which now prohibits this form of discrimination, has unlocked access to medical cover for low-to-middle income earners who might previously have believed that it was beyond their grasp.

“People often believe that medical aid is the same thing as health insurance,” said Sonja Visser, CEO of African Unity Life (AUL).

“However, in reality, the two are very different. Health insurance is usually much more affordable and, as a result of the new regulations, this type of cover is now available to everyone.”

Before choosing between medical aid and health insurance, Visser said it is important to understand the differences and benefits of each product type.

Who qualifies?

Previously, only medical aids were obliged to provide all applicants with cover however the new regulations make it mandatory for health insurance providers to grant cover as well. In both cases however, a three-month general waiting period, and a 12-month pre-existing condition exclusion can be imposed.

“The intention of insurance is to protect people against unforeseeable circumstances,” said Visser.

“These restrictions prevent individuals from only taking out insurance when they know that they are likely to require medical treatment, only to cancel the policy immediately after treatment.”

Paying for cover

Medical schemes must charge all members of a given plan the same premium and cannot adjust the rate based on risk factors such as age, medical history, lifestyle or health status.

Prior to the introduction of the Demarcation Regulations, insurance products could vary the amount they charge based on these considerations. However, now they are also required to charge all members equal rates.

Higher premiums may however be charged to members according to the age at which they enter into an insurance agreement, provided the same charges are applied to all members taking out cover within that age category.

What you are covered for?

Medical aids are required by law to provide all their members with a minimum level of mandatory cover, called Prescribed Minimum Benefits (PMBs), which covers treatment for 26 of the most commonly occurring ailments and over 270 other conditions.

Visser points out those insurance providers, on the other hand, are not obligated to provide a minimum set of benefits or to provide cover for common or expensive treatments.

“This means that health insurance products can be priced at a far more affordable rate. Policyholders must carefully read their policy document to ensure that they are aware of what they are covered for.”

According to the Council of Medical Schemes, the current Chronic Disease List (CDL) includes:

  • Addison’s disease
  • Asthma
  • Bipolar Mood Disorder
  • Bronchiectasis
  • Cardiac failure
  • Cardiomyopathy
  • Chronic obstructive pulmonary disorder
  • Chronic renal disease
  • Coronary artery disease
  • Crohn’s disease
  • Diabetes insipidus
  • Diabetes mellitus type 2
  • Diabetes mellitus type 1
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson’s disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus
  • Ulcerative colitis

Payment of claims

Medical aid providers will pay medical bills on behalf of a member. This might include paying for hospitalisation, medical procedures, doctor’s consultations and certain medications.

They pay medical aid rates, which should sufficiently cover costs. However, sometimes specialists charge more, Visser said.

“In this case, Gap Cover can be taken out to fund any shortfall between the amount covered by the medical aid and the medical service provider charge.”

On the other hand, medical insurers are prohibited from paying medical institutions directly for medical expenses. Instead, a daily amount of up-to R3,000 or a lump sum of up-to R20,000 per annum can be paid to the principal member directly for non-medical expenses incurred due to hospitalisation. It is up to the beneficiary to decide what should be done with the money.

“Although health insurance differs from medical aid, its affordability makes it more accessible to low-to-middle income earners,” said Visser.

“The introduction of new regulations now mean that more people can enjoy its benefits.”

Read: 4 major new bills have just been approved by Cabinet – here’s what you need to know

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