Health Insurance: Frequently Asked Questions
1. What is health insurance?
Health insurance is a policy that provides defined benefits for specific medical services, usually at private healthcare providers, for a fixed monthly premium.
2. How is health insurance different from medical aid?
Medical aid schemes are regulated by the Medical Schemes Act and must provide Prescribed Minimum Benefits (PMBs). Health insurance is regulated under short-term or long-term insurance legislation and provides fixed, policy-defined benefits rather than comprehensive cover.
3. Who is health insurance suitable for?
It is typically suitable for individuals or families who want affordable access to private healthcare but cannot afford full medical aid cover.
4. Does health insurance cover hospitalisation?
Some plans include limited hospital cover for defined procedures or networks. Cover is not as comprehensive as medical aid hospital plans.
5. Is health insurance accepted at all doctors and hospitals?
Most health insurance products operate through specific provider networks. Benefits usually apply only when using approved network providers.
6. What benefits are typically included?
Depending on the plan:
GP consultations
Basic dentistry
Optometry
Acute and chronic medication (on formulary)
Basic pathology and radiology
Limited hospital procedures
7. Is chronic medication covered?
Certain chronic conditions may be covered if they are listed on the insurer’s chronic formulary and managed through the approved process.
8. Are there annual limits?
Yes. Benefits are usually subject to annual limits per person and per benefit category.
9. Are there sub-limits?
Yes. For example, there may be limits on dentistry, optometry, or specific procedures.
10. Is maternity covered?
Some plans offer limited maternity benefits, often subject to waiting periods and caps.
11. Does it cover pre-existing conditions?
Pre-existing conditions are usually subject to waiting periods, exclusions, or limited cover depending on underwriting.
12. Does it include emergency cover?
Emergency stabilisation may be covered at specific facilities or up to a defined limit.
13. Who can join?
South African residents within specified age limits, depending on the insurer’s product rules.
14. Are there age limits?
Yes. Entry age is usually restricted, and certain plans may have maximum entry ages.
15. Is there medical underwriting?
Yes. Applicants must disclose medical history. The insurer may apply:
Waiting periods
Exclusions
Premium loadings
16. What are waiting periods?
A waiting period is a defined period after joining during which certain benefits are not accessible.
17. Can my application be declined?
Yes. If the risk is considered too high, the insurer may decline the application.
18. Can I add dependants later?
Yes, subject to underwriting and possible waiting periods.
19. How do I access benefits?
Typically by:
Visiting a network provider
Presenting your membership card
Obtaining pre-authorisation where required
20. Do I need pre-authorisation?
Certain procedures, hospital admissions, or specialised treatments require pre-authorisation.
21. What happens if I use a non-network provider?
Benefits may not be paid, or you may be liable for additional costs.
22. How do I get chronic medication?
Chronic conditions must be registered and medication obtained through approved pharmacies.
23. Is there a call centre or app?
Most insurers provide member portals, mobile apps, or call centres for benefit verification and authorisations.
24. What do I pay monthly?
You pay a fixed monthly premium based on your selected plan and family size.
25. Are there co-payments?
Some services may require co-payments or fixed contributions.
26. Can premiums increase?
Yes. Premiums typically increase annually and may also adjust based on claims trends or age.
27. Does health insurance qualify for medical tax credits?
No. Only registered medical aid scheme contributions qualify for medical scheme tax credits.
28. Can I cancel my policy?
Yes, subject to notice periods as stated in the policy terms.
29. What happens if I miss a premium?
The policy may lapse after a grace period, and benefits will not be accessible while unpaid.
30. How are claims submitted?
Network providers often claim directly. For reimbursement claims, members submit invoices and proof of payment.
31. How long do claims take to process?
Processing times vary but are generally within a few working days once all documents are received.
32. What if my claim is rejected?
You will receive a reason for rejection. You may:
Submit additional documentation
Lodge a formal dispute
33. Can I escalate a complaint?
Yes. If unresolved internally, you may approach:
The insurer’s compliance department
The FAIS Ombud
The relevant insurance ombudsman
34. What documents are required for disputes?
Policy number
Claim reference
Supporting invoices and reports
Written explanation of the dispute
