Pensioners are unfortunately faced with some of the toughest circumstances when it comes to medical aid cover. On one hand they have limited finances in their retirement years, and on the other they need more medical care due to chronic conditions that are part and parcel of the senior years. The thought of long lines at a public hospital coupled with all the other nuances that make most people dread public healthcare means that the service of private practitioners and hospitals is the only option. But private healthcare in South Africa is ridiculously expensive and without medical aid it is unaffordable for most people. So what are the options for seniors looking for medical aid, or for children seeking appropriate cover for parents and grandparents?
Cover for Parents and Grandparents
Medical aids in South Africa will allow for children to cover their parents on their medical aid, provided that it can be shown that the parent is a dependant (in the financial sense) on the main member, or spouse dependant. The same applies for grandchildren. It may be a better option for some where employers are subsidising the medical aid contributions and are open to the idea of subsidising parents and grandparents, be it through a company medical aid or other restricted scheme like GEMS for government employees.
However, it is not always the best choice for several reasons. Firstly, older dependants may utilise more day-to-day dependants at the expense of other dependants on the same plan. Naturally seniors will need more medical care. It is not as much of an issue with the chronic benefit or hospital benefits as these are subject to prescribed minimum benefits (PMBs) and a very large annual limit respectively. PMBs are a set of 25 chronic conditions that are considered serious and life-threatening for which medical schemes must cover unlimited throughout the year.
Read more on medical aid dependants over 21 years.
Medical Cover for Pensioners
The other option is for pensioners to get their own medical aid and pay for it themselves. These days there are several cheaper options that are based on the income of a person. It has its restrictions like only allowing members to see certain private practitioners or visit only certain private hospitals within the network, but it still offers private healthcare at a lower price than more expensive plans. One such popular option these days is the Discovery KeyCare series of plans. However, many other schemes have similar plans.
Pensioners need to assess the plan they select very carefully. It is pointless being restricted to a network hospital that is not near to their home. Emergency medical assistance means that a person has to be able to access a facility as fast as possible. The other issue is that the medical aid that pensioners choose has to be affordable in the long term. Simply affording the premium for a few months and then giving up cover is a waste of time and money. Rather take a cheaper plan that can be afforded every month for the long term.
Restrictions, Exclusions and Rates
Pensioner Waiting Periods
There is no specific waiting period on medical aid for a pensioner. There are two types of waiting periods that applies to every new member. First is the general waiting period of 3 months where the medical aid will not pay for any claim. The second is the pre-existing condition waiting period of 12 months where the medical aid will not pay for any claim related to a condition that existed before joining the medical aid. Attempting to deceive the medical aid through non-disclosure of pre-existing conditions can have serious implications.
Late Joiner Penalty
Every person of any age up to 35 years will pay the same monthly contribution for the same plan irrespective of age, health status or lifestyle. Medical aids do not alter contributions based on individual risk profile like a life insurance policy. However, any person starting up on medical aid after the 35 years is subject to a late joiner fee. This is a type of penalty that is added to the monthly medical aid contribution. It varies depending on the age that a person joins the scheme as well as whether they had previous medical aid cover in the past.
Read more on joining a medical aid after 35 years.
Pensioners, like every South African consumer of any age, need to be aware that there is no alternative to a medical aid. Neither a hospital cash back plan nor a medical insurance plan can match or offer what medical aid covers. These other products definitely have a place in the South African market and can be beneficial cover above and beyond medical aid but pensioners should not be misled in believing that they are getting the same type of cover as that offered by medical schemes.
Gap cover, another handy add-on to medical aid, pays the difference between what the medical scheme pays and what the doctor demands as compensation. It is not an alternative to medical aid. Rather it should be seen as an optional extra to protect against the shortfall in payouts to the doctor, especially these days when some practitioners charge up to 3 times the medical aid rate. Unfortunately gap cover is a short term insurance that usually does not cover seniors over 65 years of age.