Medical Aid · Educational Guide

Medical aid and a hospital plan aren't the same thing — know which one you actually have.

A plain-English breakdown of what your scheme option actually pays for, the most common gaps, and what really drives your contribution.

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The basics

What's actually covered — and what isn't

Covered — In-hospital treatment on your chosen option

Admissions, procedures, and specialists covered according to your plan's benefit table.

Not covered — Costs above scheme rate

If a specialist charges more than your scheme's rate, you carry that shortfall unless you have gap cover.

Covered — Chronic medication on the PMB list

Prescribed Minimum Benefit conditions must be covered by law, regardless of plan option.

Not covered — Non-PMB chronic conditions on some plans

Certain chronic conditions outside the PMB list may only be covered on higher-tier options.

Covered — Day-to-day claims where included

GP visits, dentistry, and medication if your option includes a day-to-day or savings benefit.

Not covered — Cosmetic or purely elective procedures

Almost universally excluded across scheme options.

Cover gap check

The four gaps that catch medical scheme members out

No gap cover for shortfallsThe difference between scheme rate and what a specialist actually bills isn't covered by the scheme itself.
Savings depleted mid-yearDay-to-day savings run out well before December, leaving costs to pay from pocket.
Chronic condition not registeredBenefits for a diagnosed chronic condition only apply once it's formally registered with the scheme.
Wrong option for family sizeA plan chosen years ago may no longer suit a growing family's actual usage.
Pricing factors

What actually drives your monthly contribution

Factor 01

Plan option chosen

Hospital-only options cost less than comprehensive options with day-to-day cover.

Factor 02

Number of dependants

Each additional adult and child dependant adds to the total contribution.

Factor 03

Age at joining

Joining later in life can trigger late-joiner penalties on top of the base contribution.

Factor 04

Chronic disease registration

Registering a diagnosed condition unlocks the cover you're legally entitled to.

Factor 05

Network vs open provider choice

Network-restricted options are typically cheaper than open, any-provider options.

15 minutes. No pressure. Just clarity.

We'll go through your current scheme option and flag where the gaps between what you think is covered and what actually is.

How it works

Three steps, start to finish

Book a 15-minute call

Pick a slot that works for you — no forms to fill in first.

We review your situation

Your current cover, your goals, your budget — a proper needs analysis, not a quote bot.

You get a clear recommendation

Only once I understand your situation — never before.

Questions

Common questions

Is this page giving me financial advice?

No. This page is educational only. Personalised advice only happens after a proper needs analysis on a call, as required under South African financial services regulation.

Is medical aid the same as gap cover?

No — gap cover is a separate short-term policy that covers the shortfall between what your scheme pays and what a provider actually bills.

Can I switch medical schemes at any time?

Generally you can only switch options or schemes once a year, and certain waiting periods may apply.