Comprehensive Plans

appleComprehensive medical aid plans provide extensive cover for almost all medical costs and include unlimited hospital cover and generous benefits for day-to-day expenses.

They are the most costly medical aid options available today but provide complete peace of mind for you and your family.

New generation comprehensive plans generally fund initial claims from a medical savings account. Once all the funds are exhausted, another risk benefit takes over, providing cover until the end of each year.

Benefits of Comprehensive Plans

  • Although you will be required to spend more money on a medical savings account, once the funds have been depleted, the level of medical cover is increased appreciably.
  • Traditional comprehensive plans generally offer unlimited benefits for GP consultations and basic dentistry and if not, then the cover is extremely generous.
  • All comprehensive plans provide chronic medication cover for all listed PMBs plus additional chronic diseases specified by the medical aid scheme.
  • A bouquet of additional in-hospital benefits, which differ according to the medical aid scheme and comprehensive plan you have selected, can include emergency trauma at out patients, post hospital cover, multi-day ‘take home’ medicine and oral contraceptives.
  • Limited benefits, which vary from plan to plan, are generally part of a comprehensive medical aid package and include restricted cover for terminal care, alcohol and drug rehabilitation, organ transplants, physiotherapy, oncology, renal dialysis, cochlear implants, prostheses, psychiatric treatment, specialized medicine and rehabilitation, private nursing, hospice and step-down facilities.

Who Should Apply for Comprehensive Plans?

Comprehensive medical aid plans are ideal for those who are getting on in years, have extended chronic conditions and/or who require widespread day-to-day benefits for regular consultations and over-the-counter medication.

What to do About a Shortfall?

Although comprehensive plans are the ‘Rolls Royce’ of medical aid cover in South Africa, they seldom fund all medical costs down to the last cent.

This is largely because specialists and other healthcare professionals are permitted to charge private rates that can be significantly higher than the tariffs calibrated by the National Health Reference Price List.

Medical aid schemes typically provide in-hospital benefits at anything between 100% and 300% of the scheme rate, while the actual cost is more likely to be around 400%.

Members often have co-payments and costs in excess of in-hospital sub-limits imposed on them too, leading to a significant shortfall in cover.

Gap cover is a cheap, additional medical aid alternative that picks up this excess and comes in a range of products designed to fill the tariff gap, the co-payment gap and the cancer sub-limits gap.