International Travel Insurance
International Travel Insurance: Frequently Asked Questions
What is a Medical Aid (medical scheme)?
A not-for-profit fund that pools members’ contributions to pay for defined healthcare benefits under the Medical Schemes Act, regulated by the Council for Medical Schemes (CMS). Core protections include open enrolment, community rating and Prescribed Minimum Benefits (PMBs).
How is medical aid different from “health insurance”?
Medical aid must cover PMBs in line with law and operates under the Medical Schemes Act (CMS oversight). “Health insurance” (incl. hospital cash plans) is short-term/long-term insurance regulated by the FSCA/Prudential Authority under the Demarcation Regulations and is not a substitute for scheme membership.
Open vs restricted schemes — what’s the difference?
Open schemes accept anyone (subject to underwriting). Restricted schemes limit membership to specific employer groups/professions. Both are regulated by CMS.
What are PMBs?
Minimum benefits all schemes must cover:
• Any emergency medical condition
• 271 diagnosis–treatment pairs (mostly in-hospital)
• 26 chronic conditions on the Chronic Disease List (CDL)
Coverage is typically in full when you use the scheme’s Designated Service Providers (DSPs).
Do I have to use a DSP?
For PMB care, using DSPs usually ensures full payment; voluntary use of a non-DSP can trigger co-payments (emergencies are treated differently).
Are chronic medicines covered?
Yes for the 26 CDL conditions (subject to formularies and DSP rules). Non-formulary choices may attract co-payments.
Can a scheme impose waiting periods?
Yes. By law, schemes may apply:
• General waiting period: up to 3 months (you pay contributions; benefits may be limited — PMB access depends on prior cover category).
• Condition-specific waiting period: up to 12 months for pre-existing conditions (PMB access depends on prior cover category).
Access to PMBs during waits depends on your previous membership status and timing of joining.
How do waiting periods work if I’m pregnant when joining?
Pregnancy is treated as a pre-existing condition. A 12-month condition-specific waiting period may apply to pregnancy-related costs if you join while already pregnant (PMB emergency rules still apply).
What is a Late-Joiner Penalty (LJP)?
An ongoing percentage loading on the risk portion of your contribution if you join from age 35 with insufficient prior scheme membership. Bands (years uncovered since 35):
• 1–4 years: 5%
• 5–14 years: 25%
• 15–24 years: 50%
• 25+ years: 75%
Formula: X – (35 + Y) = Z (Z = years uncovered).
Will a broker cost me extra?
No separate fee from you. Broker remuneration is regulated and paid by the scheme from contributions (capped by CMS each year).
What does “100% of scheme rate” mean?
Schemes reimburse according to their tariff (“scheme rate”). Many specialists charge above this, creating a shortfall unless your option covers higher multiples or you have gap cover.
What is gap cover and what’s the annual limit?
A short-term insurance policy that helps pay medical expense shortfalls after your scheme pays. It isn’t medical aid and can’t replace it. The overall annual limit for gap policies is adjusted by National Treasury; from 1 April 2025 it’s R219,845.96 per insured person.
Do I need authorisation for hospital admissions and tests?
Usually yes (except true emergencies). Always follow your plan’s pre-auth rules to avoid co-payments.
Can I see any doctor?
On “network” options you must use network hospitals/doctors for full cover. Even on non-network options, PMB treatment via a DSP avoids co-payments.
How are contributions set?
Schemes use community rating: same contribution for members on the same option, not based on individual health risk (underwriting uses waiting periods/LJPs instead).
Do I get a tax break for medical aid?
Yes — Medical Scheme Fees Tax Credits (MTC) reduce your PAYE: in 2025 the credit is R364 per month for the first beneficiary, R728 for the first two, and R246 for each additional dependant (unchanged for 2025/26).
What documents matter for claims?
Keep ICD-10 codes, detailed invoices, proof of payment (if applicable), and authorisation numbers.
Claims & Disputes
1 - Dispute with the scheme (member services → internal complaints/PO).
2 - If unresolved, lodge a complaint with the Council for Medical Schemes (CMS).
