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10 tips on choosing a medical scheme

08 December 2014, 12:59

Nairobi -  Medical cover can bite a huge chunk out of your income every month. How do you make sure that the cover you choose is the right one for you?

Here are 10 things you need to consider.

Full cover vs. a hospital plan. Decide whether you can afford the normal day-to-day medical expenses, such as GP visits yourself. Hospital plans are often far more affordable than full medical cover. But do remember that even hospital plans cover you for 26 specified chronic conditions (known as PMBs).

Check your health. If you suffer from chronic medical conditions, such as diabetes or arthritis, you might need full medical cover rather than only a hospital plan. If you are generally healthy, but have eyesight or dental problems, choose a scheme that makes adequate provision for this.

Assess your finances. Full medical cover can be expensive and if you can't afford it, you can't afford it. If you have a monthly income of KES30000, you cannot spend KES10000 of it on medical cover, whatever others may say. If you do decide to join a scheme, also check who gives you the best deal for your spouse and children, and exactly what your monthly contributions would be. The insurance plans that pay you out per day you spend in hospital very seldom cover even a fraction of the medical costs.

Check a scheme's payment record. If you have to choose an open scheme, phone your GP's secretary, or the nearest private hospital, to find out whether they have experienced problems with pay-outs from that particular scheme.

Check a scheme's solvency ratio. Any broker should be able to give you the latest information on this. The last thing you want is to pay your premiums and then find out that the scheme has gone under while you were in hospital having kidney stones removed. According to the law, schemes should have at least 25% of members' annual contributions in reserve.

Scrutinise the table of benefits. A scheme may look wonderful on paper, as they appear to pay 100% of the cost on a variety of things, but do check what the day-to-day limits are and how much your Medical Savings Account (MSA) is per year. If the MSA is small, you could exhaust your day-to-day cover by February. Also, many private hospitals do not charge medical scheme rates - you could be landed with a nasty bill after your hospital stay, despite having hospital cover. Check what co-payments you will have to make on all bills. It might be an idea to go for an option that pays 200% of the medical fund rate for hospital treatment. And do check what they pay for cancer cover: you don't want a nasty surprise.

See an independent broker. This person is not paid to promote a single scheme, and will be able to help you choose the scheme that will be the most beneficial to you.

Find out about exclusions. Some schemes may exclude you from claiming for certain conditions for a limited period of time (usually not more than one year). Be aware of these possible exclusions before signing on the dotted line. Also, if you are not coming straight from another scheme, and this is the first time you join, you can usually not claim for day-to-day expenses in the first three months.

Check overall hospital limits. If a scheme limits its hospital payouts to R500 000 per family per year, what would happen if you were all in the same accident? Find out what a week or two in hospital would cost for you and your family - you may be shocked.

Check HIV cover. In a country where one in every nine people is HIV-positive, this is important. How much would a medical scheme contribute should you become HIV-positive and, in time, require a lengthy hospital stay?

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- Health24


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