Understanding hospital cover vs comprehensive medical cover in South Africa

Home » Understanding hospital cover vs comprehensive medical cover in South Africa

As a professional living in South Africa, understanding the intricacies of our healthcare system is crucial to making informed decisions about both your health and finances. Everyone in South Africa has access to the state hospitals and clinics. Healthcare services are free, but with such a large population, many of whom rely on national healthcare service, waiting times can be extremely long.

As a result, there are many private hospital and day clinic groups across the country, as well as private general practitioners (GPs) and other specialists. Private medical cover allows scheme members to access these private healthcare services affordably.

The two key choices within this system are hospital cover and comprehensive medical cover. These two options may sound similar, but they are quite different in their nature and coverage, offering a range of benefits tailored to different stages and needs of life.


Hospital cover vs. comprehensive medical cover

Hospital cover, as the name suggests, provides cover related to hospitalisation. This includes the costs of being admitted to the hospital, surgeon and anaesthetist fees, medication administered in the hospital, and necessary procedures performed during your stay. However, it’s important to note that it does not cover out-of-hospital medical expenses.

On the other hand, comprehensive medical cover offers more benefits. Not only do they cover hospitalisation costs, but they also cover day-to-day medical expenses like GP visits, prescribed medication, dental care, eye care, and even chronic disease management. South Africa’s Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected, specifically for chronic conditions, but comprehensive cover does offer better health management and quality of life.

Selecting between hospital cover and comprehensive medical cover should be informed by a range of factors, including your current and future health needs, your age, dependants, and budget. Let’s review the pros and cons of both options.


The pros of hospital cover

  • Hospital cover is generally less expensive than comprehensive medical aid cover, making it more affordable and accessible to a wider range of people.
  • If you’re primarily concerned about potential hospitalisation costs, hospital cover provides targeted protection.


The cons of hospital cover

  • Hospital cover does not pay for out-of-hospital expenses, which can be significant, particularly for those with chronic conditions.
  • Routine medical expenses such as GP visits and prescription medications are not covered.


The pros of comprehensive medical aid cover

  • Comprehensive options cover both in-hospital and out-of-hospital expenses, offering a safety net for a wider range of health issues.
  • There are generally many benefit options to choose from, which means you can tailor your plan to your specific needs. For example, you can select comprehensive cover but on a network hospital option, which means you need to go to a network hospital that has a special rate agreement with the medical aid.
  • These options often include benefits for managing chronic conditions, which can help prevent serious complications and costly hospital stays.


The cons of comprehensive medical aid cover

  • Comprehensive options are generally more expensive due to their wider coverage.
  • There are many benefit options to choose from and many first-time members feel overwhelmed by choice.
  • At Profmed, our expert consultants and skilled intermediaries are always available to guide you through this process, and assist you with making the correct choice. Compare Profmed benefits here.


What’s the best option for me?

Young, healthy individuals without family responsibilities might find a hospital option more suitable. It provides adequate cover for unexpected hospitalisation while keeping monthly contributions low.

However, anyone with family responsibilities or chronic health conditions should seriously consider comprehensive medical aid. These options cover routine health expenses and provide important benefits for managing ongoing health conditions.

It’s worth noting that in South Africa, if you join a medical aid after the age of 35, you may have to pay a late joiner penalty.

The choice between hospital cover and comprehensive medical aid cover is a personal one, based on your health, family circumstances, and financial resources. Regardless of your choice, understanding these options can empower you to take charge of your health and make informed decisions that benefit you in the long run.