As a young adult you may not see the need for full medical aid cover and rightfully so. Most of the time, younger people are less likely to fall ill and need extensive medical care out of hospital. If you are a student then you may have access to some primary healthcare services on campus. Apart from the odd dental or GP consult, your medical needs are usually minor. However, any calamity can occur and you may need financial protection most when you are in hospital.

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What is a hospital plan medical aid?

A medical aid with hospital plan only is cover that does not extend to out-of-hospital services. This means that you can receive treatment within a hospital and the medical aid plan will pay accordingly. Chronic cover is also included in hospital plan medical aids. However, your visits to a doctor, medication and diagnostic investigations like blood tests and scans will not be covered if you have not been admitted to a hospital (outpatient basis).

Depending on the choice of hospital plan medical aid, you may be covered for treatment in any private hospital or be limited to certain private hospitals. These are known as network hospitals. It is crucial to establish at the outset whether the medical aid hospital plan you choose is restricted to network hospitals or will cover all or most private hospitals.

It is important to distinguish a hospital plan medical aid from other types of hospital plans. Many students and less informed healthcare consumers often make a mistaken between these products. There is a difference between health insurance and medical aid. The former, health insurance as well as medical insurance, may also have hospital plan options but these are not medical aids.

What will a medical aid hospital plan cover?

It is important to note that there are several options among hospital plans on the same medical scheme.  These options vary by the benefits and the price also varies accordingly. If you are prepared to pay more then you can afford a medical aid hospital plan with more extensive benefits. Despite these differences in benefits, all medical aid hospital plans cover similar services and products.

Firstly, a medical aid hospital plan will only pay for in-hospital treatment. This includes the hospital stay. However, it only applies if you are admitted to hospital for an essential service. In other words, cosmetic surgery and other non-essential medical care will not be covered by the medical aid hospital plan. However, in recent years more medical schemes are covering at least part of the cost of weight loss surgery for obese members who qualify.

Secondly, a medical aid hospital plan will cover healthcare practitioners (doctors and specialists), various treatments (like surgery), tests (like blood, urine and stool tests), scopes (like a colonoscopy) and scans (such as an ultrasound, x-ray, CT scan and MRI). However, these services will only be covered if deemed necessary.

Some medical schemes will refuse payment until a doctor motivates for it or pay only a portion of the cost of these services. Additional medical care by auxiliary healthcare providers like physiotherapists or psychologists may also be covered depending on the diagnosis and whether authorisation is approved before the practitioner sees the patient.

How much do hospital plan medical aids cover?

As with the extent of benefits and services covered, a hospital plan may have an annual limit for medical care within a private hospital. Most of the time these limits are sufficiently high to cover most medical needs, including surgery, ICU care and other procedures that are expensive. Some higher end plans may have unlimited cover for hospital care.

It is also important to confirm the percentage of medical aid tariff that the medical aid hospital plan will cover. For example, most plans will cover 100% of medical aid tariff. However, network plans will only cover 70% of the costs if you have treatment in a hospital outside of the network. At the other end, higher plans may cover up to 300% of medical aid tariffs.

With may private practitioners now charging more than 100% of medical aid tariff for their services, you could still be out of pocket for hospital care even though you have a medical aid. This is where a higher end medical aid hospital plan can be of benefit or alternatively medical gap cover will protect you against any shortfall.


  1. These are the best-rated hospital plans in South Africa. BusinessTech