Medical Aid, Health Insurance & Gap Cover: A Comprehensive Guide

Healthcare services are a necessity to have in today’s uncertain times but there are many options from which to choose: health insurance, medical aid and Gap cover. If you, like many South Africans, are unsure what type of cover would suit you and provide value for money, take a look at this comprehensive guide from Bloom.

Understanding health insurance

Medical or health insurance is a cost-effective cover that aims to pay for medical-related and day-to-day expenses. Health insurance is governed by the Short-Term Insurance Act and covers preselected benefits with a monetary value attached to each. Typically, health insurance covers medical expenses, chronic medication and provides limited hospital coverage, which is usually limited to emergencies only. Medical services and care are serviced through a network of approved providers. It can also include routine annual health assessments, vaccinations, and death or funeral cover. Health insurance benefits do have waiting periods that are dependent on each product or benefit that a member has selected.

Benefits of health insurance

Having a good health insurance plan can help protect individuals and families from the high cost of healthcare, so you don’t have to use your own savings to cover expenses. It also guarantees access to private medical treatment and services. The main benefits of health insurance include:

  • Financial protection. Protection against the high cost of healthcare for medical services.
  • Access to private healthcare. Individuals and families are guaranteed access to top-quality healthcare facilities and services, should they require it.
  • Preventative care. Health insurance plans will provide cover for annual check-ups and assessments, which will help prevent, diagnose or manage certain diseases or chronic conditions.
  • Quality network providers. Health insurance uses an approved network of healthcare professionals, like optometrists and dentists, who are located within your geographical area.
  • Emergency care. Health insurance members are guaranteed emergency medical care, and hospitalisation, in the event of an emergency.
  • Customised cover. Policies can be tailored to meet a member’s specific needs and budget, which is known as the building block method.
  • Cost-effective. Health insurance often works out to be more affordable than medical aid as members only pay for the benefits they select. Just be aware that this means less coverage and limited in-hospital benefits.
  • Options. Health4Me offers a range of different health insurance plans so you can choose from entry-level to comprehensive cover, depending on your budget

Is health insurance cover right for me?

Health insurance is the right choice for you if you’re price-conscious and looking for value for money. The cover is designed to provide quality care for those individuals who earn less than R30,000 per month. If you feel that you don’t need the prescribed minimum benefits that come with medical aid, and would prefer to only pay for preselected benefits, this is also a good option. Just be aware that health insurance offers less cover than medical aid. So, if you or a family member has a chronic condition, or if you anticipate hospital procedures for a major surgical event, then you may want to consider upgrading to a medical aid plan.

Understanding medical aid

This type of cover is designed to provide financial protection against the high cost of healthcare by ensuring that individuals and their families have access to necessary medical treatment. A medical aid plan will cover doctors or specialist visits, prescription drugs, hospital admission and care, along with other expenses. A medical aid plan is registered with the Registrar of Medical Schemes. Members pay a monthly contribution in exchange for a set of prescribed minimum benefits (PMBs).

PMBs are applied across the board, regardless of the specific policy, in order to guarantee members’ access to health services insofar as diagnoses, treatment and care go for emergency medical events, a set of 271 medical conditions and a list of 26 chronic conditions. Discover more about this in How to get the most out of your medical aid plan.

Benefits of medical aid

This option will also provide financial protection from healthcare expenses and access to private medical treatment and services. The main benefits include:

  • Financial protection. This type of cover will protect you from the high costs of healthcare services, medical treatments and procedures.
  • Access to medical treatment in private hospitals and clinics.
  • Preventative care. The plan provides routine annual check-ups and assessments in order to identify, diagnose and treat certain diseases.
  • Access to quality healthcare professionals. The plan provides members with a network of approved healthcare providers who operate at a lower cost or rate.
  • Prescribed minimum benefits, which will cover emergency medical treatment, and chronic conditions, like diabetes or high blood pressure.

Is medical aid right for you?

Typically the premiums are higher than health insurance but you do get more coverage than medical insurance. However, if you value the importance of healthcare and are able to include the higher premiums in your monthly budget, then this is a good option for you. Medical aid is also advisable if you have existing medical conditions or anticipate requiring in-hospital or specialist healthcare services.

Understanding Gap cover

This is a type of short-term insurance option and offers additional cover between what a medical scheme or health insurance policy will pay for medical services and what the services actually costs. Many specialists, for instance, operate out of medical aid rates, which means that the member will have to cover the shortfall. So, gap cover can assist by reducing these out-of-pocket expenses. While gap cover is not a substitute for either medical aid or healthcare insurance, it can be added to an existing scheme or policy. It can also be purchased as a standalone product.

Benefits of gap cover

  • Reducing out-of-pocket expenses. Gap will reduce expenses for medical expense shortfalls.
  • Access to medical care. Gap will increase your access to certain medical care or services by covering treatments not covered by your scheme or policy.
  • Customised cover. Some gap policies can be customised to meet your specific medical needs, and fit your budget.
  • Complements other health covers. Gap cover provides complementary coverage to medical aid plans or health insurance policies.

Is gap cover right for me?

Gap cover is most useful when used in conjunction with medical aid or health insurance. So, if you can afford the gap cover premium and you anticipate requiring medical services where you will incur the cost of co-payments and out-of-pocket expenses, then gap cover is a good idea in order to save money in the long run. It’s also a good idea if you want to prioritise quality healthcare services and are prepared to invest in the best possible care for a certain medical condition.

Get the right medical cover for your needs

Get the right medical cover to suit your needs and your budget. Choose the cover by understanding exactly what the policy offers before you make a decision. Bloom suggest that you contact our team of trained insurance brokers to discuss your options.

Your journey to quality healthcare starts here.

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Momentum Health4Me is not a medical scheme product, and is not a substitute for medical scheme membership. The information provided on this website does not constitute advice in terms of the Financial Advisory and Intermediary Services Act. Momentum is a division of Momentum Metropolitan Life Limited, an authorised financial services provider (FSP 6406) and a wholly owned subsidiary of Momentum Metropolitan Holdings Limited.

Bloom Gap Cover is not a medical Scheme. Products that are offered are not the same as that of a medical scheme.

© Bloom Financial Services 2023. Bloom Financial Services (Pty) Ltd is an authorised financial services provider (FSP 50140). Bloom Gap is underwritten by Infiniti Insurance Limited a licensed non-life insurer and an authorised financial services provider (FSP No.35914)

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