Difference Between Medical Aid And Medical Insurance

Health care in South Africa is highly expensive. And it’s no secret that a very small component of the nation’s population can afford it. 

These days, even the smallest of medical procedures could end up costing you months to years’ worth of salaries, depending on what you earn. These expenses only make it all the more important to have some form of medical cover.

But where do you begin?

When searching for health care options, you may be slightly overwhelmed by all the options available to you. While these may seem great at first glance, it’s important to know the key differences between them so you can pick what works best for you.

Once you’ve done that, you can easily find a list of the top insurance companies in South Africa online. 

In this article, we’ll be discussing the main differences between medical aid and medical insurance. As well as important factors to consider before making your final decision between the two. 

What Is Medical Aid?

Before moving on to the differences between medical or health insurance and medical aid, it’s important to clarify what exactly each of these candidates entails.

Medical appointment sheet with stethoscope

Medical aid is regulated by the Medical Schemes Act no. 131 of 1998 and has a varying selection of cover, ranging from partial to full. The level of coverage within this selection – including waiting periods, exclusions, or exceptions – are regulated and should be specified in your contract. 

However, medical aid cannot refuse to cover any individual, regardless of age or health status, or even life-threatening conditions. A comprehensive plan would cover day-to-day medical expenses, in-hospital expenses, and everything in-between.

But this option is not necessarily affordable for the majority of South African citizens. And that’s where medical insurance comes in.

What Is Medical Insurance?

Unlike medical aid, medical insurance may not include pre-existing health conditions and generally places focus on major life events. These include hospitalization, accidental injuries, or illnesses that may occur once you have taken out an insurance policy. 

Medical insurance is regulated by the Financial Services Act, and, in most cases, one premium can cover the whole family, with the option of adding death or funeral cover. It covers medical treatments in stated amounts regardless of the actual cost of the procedure. 

Medical Aid vs Medical Insurance: What’s The Big Difference?

These terms are often used interchangeably, but when taking a closer look, you’ll find that they’re not the same thing at all.

Doctor holding a clipboard

Some may think that any kind of medical scheme cover is better than no medical cover, regardless of what kind of cover it may be. While that may be fine in some cases, you want to make an informed decision so that your medical plan of choice works in your favour. 


  • In the case of medical aid, day-to-day medical expenses are covered by the member’s chosen company on their behalf.
  • Medical aid companies are legally obliged to appoint Prescribed Minimum Benefits (PMBs) for a list of 27 chronic illnesses and disorders. These include, but are not limited to, asthma, diabetes, cardiac conditions, disabilities, etc.
  • With medical insurance, the member is paid a set amount directly, regardless of the actual total cost, either per incident or per day spent in the hospital. 
  • Both medical aid and medical insurance can provide day-to-day cover for visits to the doctor as well as prescribed medications. However, the latter is fairly limited and so the bulk of these everyday costs are paid by the members themselves.

Exclusions And Limitations

  • Medical aid is not authorised to provide death or funeral cover, whereas medical insurance is.
  • While medical aid companies legally cannot refuse to cover specific individuals based on specific factors (such as age, pre-existing conditions, disabilities, etc), medical insurance companies can.

Price And Payments

  • Medical aid is, without a doubt, a much pricier choice. Medical insurance, on the other hand, tends to be more affordable for the average South African.
  • Medical aid companies pay the medical service provider directly, whereas, often with medical insurance, a fixed or stated amount is paid directly to the member. With this, they would settle the costs involved with the incident, regardless of the actual amount needed to be paid. 

Should I Get Medical Aid Or Medical Insurance?

There’s no right or wrong answer to this question. Every person’s situation is different, and so their choice of medical scheme would naturally be different too. 

If you’re still feeling unsure, there are a number of factors to consider when choosing a medical plan. Potential buyers should try to bear in mind:

  • General medical requirements – from chronic diseases to a high-risk workplace, the medical plan and the price you pay for it may depend on these factors.
  • Age – older individuals are high-risk, and so are likely to pay a higher amount of money on their premium. For senior individuals wanting to invest in medical cover, it could be a good idea to compare funeral cover all in one go. 
  • Dependants – some medical schemes may offer different rates depending on how many people are being covered under a single plan, so it’s important to keep an eye out for that.
  • Financial abilities – it’s good to want to have the best possible plan for yourself or your family, but it won’t be of any help if you’re not able to afford it.

Any pros, cons, and limitations of a potential plan – many exclusions and limitations are often specified in the fine print. It’s crucial to weigh your options carefully, and read the fine print before making a final decision.

Doctor's coat with pens and stethoscope

Wrapping Up Medical Insurance vs Medical Aid

Some people who can afford it may choose to have medical insurance alongside their medical aid as a ‘top-up’, just to play it safe in the case of your medical aid savings running out. 

People may opt for the option that has a lower financial cost, as long as they know it subsequently comes with fewer coverage benefits. Ultimately, the decision is entirely subjective and dependent on a range of factors specific to the individual and their lifestyle.

Either way, a big part of adulthood is having to make these tough decisions. Especially those that concern our health and well-being. And regardless of what you end up choosing, it’s wise to have any type of medical cover than none at all. 


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