Medical aid terms,
explained simply

A medical aid scheme is a pool of money that many people contribute to every month. When one of those people gets sick or needs medical care, the pool pays for it. You're essentially sharing the risk of getting sick with thousands of other people.

Your premium (also called a contribution) is the fixed amount you pay every month to stay on your medical aid — whether you use it or not. Think of it like a Netflix subscription, but instead of movies, you get access to private healthcare.

A dependant is a family member you add to your medical aid so they are also covered. A spouse and children are the most common dependants. Each dependant costs an additional monthly premium on top of yours.

A waiting period is a stretch of time after you join where the scheme won't pay for certain things. There are two types: a general 3-month waiting period (nothing covered except emergencies) and a 12-month condition-specific waiting period (pre-existing conditions not covered for a year).

A medical aid pays your actual medical bills (regulated by the Medical Schemes Act). Medical insurance — like a hospital cash plan — pays you a fixed amount of cash per day in hospital, regardless of the bill. That cash payout is usually far less than a private hospital actually costs.

Medical aid benefits run on a calendar year (January to December). Most schemes only allow plan upgrades once a year, effective 1 January — you usually choose during the year-end window. Downgrades are often allowed during the year, but upgrades mid-year usually require a life-changing event.

A co-payment is the portion of a medical bill that YOU pay — the scheme pays the rest. It's how schemes share costs with members to prevent overuse. Co-payments can be a fixed rand amount (e.g. R750) or a percentage of the total bill (e.g. 20%).

An annual limit is the maximum rand amount the scheme will pay for a specific benefit in a calendar year. Once you hit that limit, you pay the rest yourself. A sub-limit is a cap within a larger benefit — like a R2,500 limit for contact lenses within your overall optical benefit.

An MSA is a personal account within your medical aid that holds a portion of your monthly premium. This money is yours and is used for day-to-day expenses — GP visits, medication, dentist, optometrist. Once the MSA is empty, you pay out of pocket until the threshold benefit kicks in.

On savings plans, once your MSA runs out, you enter the self-payment gap — a zone where you pay all day-to-day costs yourself. Once your out-of-pocket spending reaches the annual threshold, the scheme kicks back in with the Above Threshold Benefit (ATB) — covering most day-to-day costs again.

Programmes like Discovery Vitality and Momentum Multiply are optional loyalty programmes that cost extra every month. They give discounts on gym, flights and groceries — but they are not medical cover and don't change your plan's actual benefits.

A prosthesis limit is the maximum your plan pays for internal devices — hip and knee replacements, spinal cages, stents, lens implants. The surgery itself may be fully covered, but the device has its own rand limit, and premium devices often cost more than the limit.

The hospital benefit covers costs when you're admitted to hospital — the bed, theatre fees, anaesthetist, surgeon, and specialist fees while you're there. This is the core benefit of almost every medical aid plan and is covered from the risk pool (not your MSA).

PMBs are a list of 271 medical conditions that every medical aid scheme in South Africa is legally required to cover — in full — regardless of your plan or available benefits. They include life-threatening emergencies, 27 chronic diseases, and a defined set of conditions. You cannot run out of PMB cover.

The CDL is a government-defined list of 27 chronic conditions that all schemes must cover. CDL medication is paid from the scheme's risk pool — NOT from your Medical Savings Account. This means having a CDL condition doesn't drain your day-to-day savings.

Every scheme has a list of exclusions — things it will never pay for, on any plan. Common ones: cosmetic surgery, self-inflicted injuries from breaking the law, experimental treatment, and injuries covered by other insurance (like the Road Accident Fund or workers' compensation, which pay first).

Walking into a hospital casualty (ER) is only automatically covered as a hospital benefit if you are admitted or it's a true emergency (a PMB). If you're treated and sent home — stitches, X-ray, flu on a Sunday — most plans treat it as a day-to-day claim, paid from savings or your own pocket, often with a casualty co-payment.

A network hospital or Designated Service Provider (DSP) is a hospital, clinic, or doctor that has a contract with your scheme. Using network providers means the scheme pays their fees in full — no co-payment from you. Going outside the network typically means paying a co-payment.

Pre-authorisation is when you call your scheme before a planned hospital admission or procedure to get their approval. The scheme confirms they will pay and issues an authorisation number. Without this, they may refuse to cover the claim or impose a large co-payment.

Entry-level and network plans often require you to nominate a GP from the scheme's network. That doctor becomes your first stop for all day-to-day care, and referrals to specialists must usually go through them — otherwise you face co-payments or no cover.

Each scheme sets its own tariff — the rate it will pay for medical services. If a doctor charges more than the scheme's tariff, you pay the difference. Discovery pays at "200% of DHR" for specialists on certain plans — meaning they pay up to twice the scheme rate. Doctors charging 400% of tariff will leave you with a large shortfall.

Gap cover is a separate, inexpensive insurance product (not a medical aid) that covers the shortfall between what your scheme pays and what a specialist actually charges. A good gap cover policy typically costs R300–500/month and can save you tens of thousands in unexpected bills.

Every claim must carry an ICD-10 code — an international code describing your diagnosis (e.g. J03.9 = tonsillitis). The scheme uses this code to decide which benefit pays: PMB, chronic, day-to-day or nothing. A wrong or vague code is one of the most common reasons claims are rejected or paid from the wrong pocket.

An ex gratia payment is a discretionary, once-off payment a scheme can make when your benefits have run out or something isn't covered, but there are exceptional circumstances. It's not a right — you apply, a committee reviews your case, and they can say no.

If your contribution isn't paid, the scheme can suspend your benefits — claims during the suspension aren't covered, even if you pay later. Continued non-payment leads to termination, and rejoining later can trigger waiting periods and late joiner penalties.

If you join a medical aid for the first time after age 35, schemes can charge you a late joiner penalty of up to 75% extra on your contribution. This penalises people who delayed joining. The penalty is calculated based on how many years you were an adult without medical aid cover.

An open scheme (like Discovery, Bonitas, Momentum, Bestmed) accepts any South African. A restricted scheme (like GEMS, Polmed) is only open to specific employee groups — usually government or industry workers. Restricted schemes often offer lower contributions because their member pool is more controlled.

South African medical schemes must use community rating — everyone on the same plan pays the same contribution regardless of age or health. You cannot be charged more because you are 65 or have diabetes. This is very different from short-term insurance where older or sicker people pay more.

General waiting period: 3 months where you receive no benefits at all (applies to most new members). Condition-specific waiting period: up to 12 months for pre-existing conditions you had before joining. Waiting periods never apply in a genuine life-threatening emergency, and PMBs must always be covered. Schemes must disclose all waiting periods in writing before you join.

A broker is a licensed person who helps you select and enroll in a medical aid. They are paid a commission by the scheme — so their service is free to you. However, some brokers may lean towards schemes that pay higher commissions. PlainAid is not a broker — we provide independent comparison information only. If you request guidance through PlainAid, we call the accredited broker who contacts you a Verified Partner — independently registered, and not tied to any one scheme.

Most medical aids cover a general ward (shared room, typically 4–6 beds). A private ward (single room) is an upgrade that costs more. Some higher-tier plans cover private wards. Many network plans only cover general ward stays — always check your plan schedule before requesting a private room.

A planned (elective) admission must use your network hospital and requires pre-authorisation — fail to do this and you may pay the full bill yourself. An emergency admission is when your life is at immediate risk. Most schemes cover emergency admissions at any hospital, but you must still notify them within 24–48 hours.

Cancer treatment is covered under the hospital benefit but usually has its own annual limit (typically R200,000–R500,000 depending on your plan). Once exhausted, a co-payment of around 20% applies. Treatment must be from a scheme-approved oncologist. Chemotherapy, radiotherapy, targeted therapies, and immunotherapy are typically included.

Medical aids must cover mental health as a PMB. This includes in-hospital psychiatric treatment and outpatient psychology sessions. Most plans limit this to a set number of days in hospital (e.g. 21 days) or sessions per year (e.g. 15 outpatient). Higher-tier plans offer more generous mental health benefits.

Maternity benefits cover antenatal visits (typically 7–12), scans, hospital childbirth, and postnatal care. Most plans cover childbirth in a network hospital in full. Important: elective caesarean sections are often NOT covered — only emergency C-sections are. Register on your scheme's maternity programme as early as possible (ideally before 20 weeks of pregnancy).

Dental: Basic (check-ups, fillings, extractions) covered from savings on most plans. Specialised dental (crowns, implants) rarely covered.

Optical: Usually 1 eye test + 1 pair of frames and lenses every 1–2 years, with separate limits for frames vs lenses. Laser eye surgery rarely covered.

Pathology & Radiology: Blood tests and X-rays from savings. MRI and CT scans often require pre-authorisation and carry a co-payment of R2,000–R4,000 per scan even in hospital.

The CMS is the South African government body that regulates all medical schemes. It approves annual benefit changes, investigates complaints, and ensures compliance with the Medical Schemes Act. If you have an unresolved dispute with your scheme, escalate to the CMS at medicalschemes.co.za or call 0861 123 267.

The Medical Schemes Act (Act 131 of 1998) is the primary legislation governing medical aids. It mandates PMBs, community rating, open enrolment, and scheme governance. It also prohibits schemes from refusing membership based on health status (though waiting periods and late joiner penalties are allowed).

NHI is the government's plan to create a single national health fund where all South Africans receive basic healthcare regardless of income. The NHI Act was signed in 2024, but full implementation is expected to take 10–15+ years. Private medical aids will likely continue to exist alongside NHI during the long transition period.

The Protection of Personal Information Act (POPIA) gives you rights over your health data. Medical schemes and healthcare providers must protect your medical information, only use it for the purpose collected, and cannot share it without your explicit consent. Report misuse to the Information Regulator.

An originator is a branded medicine (e.g. Voltaren). A generic contains the same active ingredient at a fraction of the cost (e.g. diclofenac). Schemes have a generic reference price — they pay up to that price. If you choose the originator, you pay the difference. Generics are equally effective and are regulated by SAHPRA (the SA Health Products Regulatory Authority).

To get chronic medication covered outside your savings account, you must register your condition with your scheme. Your doctor submits clinical evidence and the scheme approves your registration. Without registration, chronic meds come out of your savings or you pay cash — even for conditions on the CDL. Always register as soon as you're diagnosed with a chronic condition.