Medical Aid Hospital Cover

Choosing the right hospital cover is one of the most important decisions when joining a medical scheme in South Africa. Hospital cover determines which medical procedures and hospital stays are covered, which facilities you can use, and how much you pay out-of-pocket.

Full Hospital Cover vs Network Hospital Plans

Medical schemes generally offer two types of hospital cover:

• Full Hospital Cover: You can use almost any private hospital in South Africa. This option provides maximum flexibility and peace of mind but comes with higher monthly contributions.
• Network Hospital Plans: Coverage is restricted to a specific network of private hospitals. These plans are more affordable but limit which hospitals you can use. Using a hospital outside the network may result in co-payments or full out-of-pocket costs.

What Is Covered by Hospital Plans?

Hospital cover usually includes:

• In-patient treatment for emergencies, surgeries, and serious illnesses
• Accommodation and meals during hospital stay
• Specialist consultations within the hospital
• Medical procedures and theatre fees
• Prescribed minimum benefits (PMBs)

It’s essential to check the plan details. Some schemes only cover basic hospital costs, while premium plans may include private rooms, advanced surgeries, and comprehensive specialist care.

Day-to-Day Benefits vs Hospital Benefits

Remember that hospital cover is different from day-to-day benefits. Hospital cover is for serious, in-patient treatments, while day-to-day benefits handle GP visits, chronic medication, and routine tests. Some members prefer plans with strong hospital cover but limited day-to-day benefits if they rarely visit GPs.

Choosing the Right Hospital Plan

When comparing hospital cover, consider:

• Your preferred hospitals and whether they are in-network
• Contribution affordability and annual increases
• Included specialist and surgical procedures
• Extra services such as ICU, maternity, or cancer treatment coverage
• Emergency medical transport and trauma cover

It’s also worth reviewing the hospital list and network rules for each plan. Using a non-network hospital can result in partial or zero coverage.

Tips to Maximise Hospital Cover

• Always verify that your preferred hospital is in-network if you choose a network plan.
• Consider a plan with PMB coverage to ensure treatment for critical illnesses is fully funded.
• Check whether additional services like ICU, maternity, or oncology are included or require co-payments.
• Compare multiple schemes and plan options to balance affordability and access.

Frequently Asked Questions

What is hospital cover on a medical scheme?

Hospital cover pays for in-patient treatment, including surgeries, specialist fees, theatre costs, and accommodation during hospital stays.

Can I use any hospital with my medical aid?

It depends on your plan. Full hospital cover allows almost any private hospital, while network plans limit you to specific hospitals.

Are emergency hospital visits covered outside my network?

Yes. All medical schemes must cover emergencies regardless of network restrictions, in line with Prescribed Minimum Benefits (PMBs).

Do hospital plans include maternity and childbirth?

Many hospital plans include maternity care, but coverage varies. Some network plans may require specific hospitals or pre-authorisation.

How do I choose the best hospital cover?

Compare monthly contributions, network hospitals, included procedures, and extra benefits to find a plan that matches your healthcare needs and budget.