If you have been a medical aid member for many years, you would have noticed that the annual benefits seem to get used up much earlier as each year passes. Premiums go up every year but the benefits last you much shorter periods of time. It is true that medical schemes are under financial strain but the main function of a medical aid is to protect you from the costs of health care when you are in hospital or need chronic care. These benefits are very stable in comparison to your day to day benefits.

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Why do benefits get exhausted so early?

It has a lot to do with how you use your medical aid. If you are sick very often, and so are other members on the scheme, then reasonably it will be used up sooner. Doctors’ fees do go up every year but not as much as you may think. Health care practitioners who are contracted into medical aids are experiencing dipping profits year on year as their fees do not increase to match inflation. The reality is that medical aids have also become a bit more restrictive when it comes to allocating day to day benefits for several reasons. However, these restrictions are aimed at protecting you when you need cover most – when you have a chronic disease or you are hospitalised.

But if you fell ill less often, did not use your medical aid unnecessarily and tried to manage your health care expenses partly out of your own pocket, you may find that your medical aid can last you for the year. Some medical aids now offering a gym contract with the thinking that members who exercise will be more healthy. And the healthier you are, the less likely you are to need medical care. Learning to pay cash as far as possible and then claiming back from your medical aid allows you to qualify for cash discounts and in the process save your benefits. However, most people do not want to manage their own medical costs.

The thinking is – I have medical aid so let the scheme pay for the bill.

What you should do if benefits are exhausted?

Unfortunately there are not many options if your medical aid benefits are exhausted before the year end. These days it is not unheard of for days to day benefits to be finished by March or April and the patient has to then find a way of funding their bills for the remaining 8 to 9 months. It is difficult but when you do not have any other option, you will just have to find a way to survive. Remember that even if your benefits are exhausted, this does not mean that you are going to get a discount on your medical aid premium. You still have to pay the same amount every month until the new year when benefits are replenished.

You have some options to consider if your medical aid benefits are exhausted.

  1. Pay cash when visiting your health care practitioner if you can afford it.
  2. Go to a government clinic or public hospital.
  3. Switch to a low cost medical aid that gives you access to outpatient services year round but with restrictions.
  4. Opt for a more expensive plan that will have larger benefits.

Many medical aids will not allow you to switch plans mid year. You will have to wait till the end of the year to switch to another plan with more benefits. So what do you do in the meantime?

Your options are limited. If you do not opt for one of the four options above then you will just have to wait for medical care. This is often not possible and can mean a life or death situation. Even though your medical benefits for the year are exhausted in terms of day to day benefits that pay for out-of-hospital costs, your chronic benefit and hospital care benefit should still be available. At least you can rest assured that your medical aid will pay when you need it the most – in hospital or for chronic care.

Try to budget yourself more carefully. A medical aid does not mean that you can have unlimited and unrestricted access to private health care services. Use it when you need it. Pay cash when you can. And if a consultation, over-the-counter medication or test is not really necessary, don’t go for it and use your medical aid. However, always speak to your doctor about what is necessary or not. There is no point trying to save your medical aid benefits only to compromise your health.

Exhausted Medical Aid Benefits for the Year

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