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Thread: medical aid

  1. #1
    Join Date
    Oct 2007
    Thanked 254 Times in 209 Posts

    medical aid

    i am sure most of you understand how the medical aid works...i do because we have been thru a 150 000 ordeal and luck for me my wife is on the ball so we have 3 top up policies over and above the medical aid and hospital plan...but for those who dont.

    we contact the medcial aid to get pre authorization and to enquire about the cover and what percentage...the medical aid advises us that they cover "100%"

    make sure you understand what 100 % means... to some of us it means total cost...full payment...etc etc...unfortuntely not when it come to medical aids and doctors.

    the medical aid will cover 100 % if they say they do but the problem is that the doctors charge 300 % and if his bill is R300...the medical aid only covers 100 % which is R100...and you pay the balance of R200...

    my glasses for example...the medical aid covers 100% but my glasses cost R3000 and that not even the lens included...i still have to select lens...the medical aid covers 100 % but only up to R1500...

    my point...make sure you understand all the pros and cons of medical aids and percentages...especially if you are going in for pre authorised could be lying in bed think you are covered until you get the final bill...and may need to take a second bond on your house to pay for the doctors lambo he just bought because he didnt know what else to do with all the money he makes...or the depost for his island he just purchased...yeah yeah i know he has a right to rip you off because he studied for years and question is then why couldnt i sue for the operation which i woke up on the operating table...because they cover their butts.

    in saying that i do have some good news... my mate won a case...where he sued because his wife got pregrant after 20 years of having her tubes tired...suddenly she got pregrant...they went to court won the case and were paid out a large sum of cover the kids education cost for her for the next 20 years and a few other maybe there is a light at the end of the tunnel.

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    tec0 (18-Jan-12)

  3. #2
    Silver Member
    Join Date
    Jan 2012
    Thanked 53 Times in 40 Posts
    Medical aid can be tricky and very technical. What you talking about is medical aid rates. Basically medical aid schemes have certain values for all procedures and doctors. If we talking in hospital 100% is the medical aid rates, however doctors can charge more, let's say you need to go for an opp and med aid rate for the sergeon is R1000 but he actually charges R2000 for that, which means he charges 200% and you will have to pay in the difference. To go around that you can get a gap cover which is an insurance product and for say R128pm your whole family will be covered at 400% in-hospital. Please remember that in the above case gap cover will pay up to R4000. There are different companies that offer gap cover so prices and etc will vary.

    Gap cover doesn't cover you out of hospital otherwise everything else works exactly the same. So if you go for glasses and med aid only authorizes R2000 when your glasses cost say R4000 you will be liable for the difference.

    There are many reasons why medical aids do that like fraud, abuse of funds, getting to a point where you don't have savings when you need them and etc.

    I work in that industry, if you have any questions I'd be more than happy to answer.
    ---There is no traffic at the extra mile---

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