
Medical aid premiums are taking an increasingly large bite out of household budgets. For many people, the annual increase has become something they dread rather than simply accept as another cost of living.
The problem is that healthcare costs are not going away. Nor is the need for adequate medical cover. But with premiums continuing to put pressure on household finances, people are increasingly having to ask themselves whether they can afford to maintain their existing medical aid and gap cover.
Some are looking at cheaper options. Others are considering reducing their cover or dropping certain benefits altogether.
But how do you review your medical aid and gap cover without leaving yourself exposed when you need medical treatment?
It is not simply a matter of comparing premiums and choosing the cheapest option. Every medical scheme has different benefits, restrictions, networks and conditions. Moving to a cheaper plan can mean giving up benefits that you might only discover you need when faced with a medical emergency.
When should you review your cover?
The annual review period towards the end of the year is a good time to examine your medical aid and gap cover arrangements.
Medical schemes announce their premium increases and changes to benefits for the coming year, giving members an opportunity to assess whether their existing arrangements still make financial sense.
Don’t wait until the last minute. Give yourself enough time to examine the alternatives, ask questions and understand what you might be giving up before making a decision.
Start with what you actually use
A sensible review begins with looking at your healthcare expenses over the past 12 months.
Examine your claims history. How often have you visited a GP? Have you needed specialist consultations? What have you spent on chronic medication? Have there been hospital admissions or other significant medical expenses?
This information can help you understand which benefits matter most to you.
It is easy to pay for a comprehensive package without knowing exactly which benefits you use. Equally, it is easy to underestimate the importance of certain benefits simply because you haven’t needed them recently.
Your medical aid should reflect your actual circumstances, but it should also provide reasonable protection against unexpected medical expenses.
Examine the changes to your existing plan
Before looking elsewhere, find out exactly what your current medical scheme is changing.
There are several things worth examining:
• How much will your monthly premium increase?
• Are your day-to-day benefits changing?
• What happens to your medical savings allocation?
• Are there changes to hospital networks?
• Are your preferred doctors and specialists still accessible under your plan?
• Have co-payments, exclusions or other restrictions changed?
Don’t assume that because you are staying with the same medical scheme, you will receive exactly the same benefits next year.
Read the new benefit guide carefully. If something is unclear, ask your broker or medical scheme to explain it.
Consider your changing healthcare needs
Your medical requirements can change considerably over time.
You may have acquired a chronic condition, started taking regular medication or found yourself needing more frequent consultations with specialists.
Family circumstances also change. You may have added dependants or have children who are no longer financially dependent on you.
The plan that made sense several years ago might no longer be appropriate.
This is particularly important for people approaching or already in retirement. When income becomes more constrained, medical aid premiums can become one of the largest items in the monthly budget.
Reducing the premium might seem attractive, but the consequences need to be carefully considered.
Review medical aid and gap cover together
This is one of the most important parts of the exercise.
Medical aid and gap cover perform different functions, but they should be considered together when reviewing your healthcare protection.
Medical aid provides the underlying cover, subject to the benefits, rules and conditions of your chosen plan. Gap cover is designed to assist with certain qualifying shortfalls between what medical schemes pay and what healthcare professionals charge.
If you change your medical aid plan, you should examine whether your existing gap cover remains appropriate.
A cheaper medical aid option might have different co-payments, limits and restrictions. You need to understand how these interact with the benefits provided by your gap cover.
Equally, moving to a more comprehensive medical aid plan does not necessarily mean that you should automatically retain exactly the same gap cover arrangements.
Examine what each policy actually covers and where the benefits overlap.
Remember that gap cover is not a substitute for medical aid. It cannot simply be relied upon to pay for treatments or services excluded by your medical scheme.
When comparing medical aid and gap cover options, the monthly premium is obviously important. But it is only one part of the equation.
A cheaper plan may look attractive until you examine the limitations.
Consider the following:
• Hospital cover: What level of hospital treatment is covered, and under what conditions?
• Hospital networks: Are you restricted to particular hospitals or healthcare providers?
• Co-payments: What additional amounts might you have to pay for certain procedures?
• Specialist fees: How are specialists’ charges covered?
• Chronic medication: What conditions and medications are covered?
• Gap cover limits: What are the maximum amounts payable, and are there restrictions on particular claims?
• Waiting periods: Are there waiting periods or exclusions that could affect your ability to claim?
Ask for the relevant policy documents rather than relying on a sales presentation or a comparison table.
The downscaling dilemma
For many households, the uncomfortable reality is that existing medical aid arrangements are becoming increasingly difficult to afford.
Moving to a cheaper plan may be necessary, but it should not be an impulsive decision.
The temptation is to look at the monthly saving and regard it as money back in your pocket. But what happens when you need an operation, specialist treatment or hospital admission?
You could find yourself facing additional expenses that wipe out much of the saving you made on premiums.
The objective should be to find the most affordable combination of medical aid and gap cover that still provides an acceptable level of protection.
That requires looking beyond the headline premium and examining the details of the benefits and limitations.
Get independent advice
Medical aid and gap cover products can be complicated. Comparing one scheme against another is not always straightforward, particularly when the benefits and exclusions differ.
An independent broker can help you examine the alternatives, explain the differences and identify potential gaps in your cover.
Ask questions. Get comparisons in writing. Make sure you understand what you are gaining and what you are losing before signing up for a different arrangement.
Ultimately, the decision comes down to balancing affordability against the financial risks of inadequate medical cover.
Medical aid should not be something you simply renew every year without examining the cost and benefits.
With healthcare expenses putting increasing pressure on household budgets, an annual review has become an important part of managing personal finances.
The challenge is to reduce unnecessary costs without sacrificing protection that could prove invaluable when you need it most.
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