Medical aids, hospital plans, medical insurance and so on can make your head spin. Having some kind of medical cover is vital and yet navigating your way through what each option means and how it assists you, is tricky. Every single medical cover company has different options and a variety of packages that cover various different instances. The South African government has put into place something called the prescribed medical benefits (PMB). PMBs have been defined as medical benefits that allow every single person, who has medical cover, access to health services that are considered the minimum set of services regardless of the type of cover they have opted for. These defined benefits have been implemented as the South African government aims to provide everyone with care that will improve their health. This means that basic healthcare is affordable and everyone’s quality of healthcare is improved.
PMBs have been listed and defined and are determined through a diagnosis-based approach
According to the Medical Schemes Act, the PMBs cover the expenses which relate to a patient’s diagnosis and treatment when in an emergency medical condition, suffering with one of the 270 predetermined medical conditions or if the patient is suffering from one of the 25 chronic diseases on the Chronic Disease List. The approach to determining whether a patient is suffering with a condition that is listed as a PMB the medical practitioner must use a diagnose-based approach. This means the symptoms are the only factors that the doctor must account for when deciding if the condition is a PMB.
What’s more, PMBs don’t operate with any exclusions. The medical cover service providers can exclude procedures that they won’t cover but if a patient ends up with a condition after having had an excluded procedure performed then they must be covered according to the PMBs list.
Medical insurance is often misconstrued as simple another way of referring to medical aid
The internet abounds with information about medical cover. You can quickly find information on what it means to have comprehensive medical cover or to opt for a hospital plan only. You can discover the different packages available through the different medical aid companies and most are happy to respond quickly to your queries either over the phone or via email. But there’s a new kid on the block. There is now the option of medical insurance, while it is not a brand new idea it is certainly one that many don’t know about or regard as an interchangeable term with medical aid, which is incorrect.
Many South Africans have experienced less than optimal care when suffering with illness or have found themselves with not enough money in their medical funds when they have been in an accident. Many people opt for not going to the doctor but rather trying nurse themselves back to health because medical care is incredibly costly. The horror stories of being administered less than the best care when it’s needed are unfortunately rather common. Medical insurance aims to offer everyone, no matter their pay grade, medical cover when they need it the most.
Here’s the definition of medical insurance
Medical insurance is offered by day to day medical insurance companies and it is often seen as bridging cover between hospital fees and the costs that medical aid coverage won’t pay. It’s considered to be a type of short term insurance product and is governed and regulated by the Short Term Insurance Act in South Africa. Because of this the monies paid out to the patient are not bound by the terms and conditions of the Medical Schemes Act. This means that the things that medical aids cannot provide cover for, medical insurance can. Examples include the coverage of death and funeral cover, personal accident disability and the loss of limbs.
While there are a very many (perhaps too many) medical cover options available there is a real effort being made by the South African Government, South African Medical Schemes Act and so on, to curb the lack of optimal healthcare to the country. Healthcare should be available to all members of society and while our public sector hospitals struggle with the influx of patients daily, the private sector is being made to be more available to the average working person more so than ever before.