monthly levies of about R45,000, in addition to a non- and include all emergency conditions, 270 specified medical
refundable life right fee. Full-time home-based care can be conditions (called diagnosis treatment pairs), and 25 chronic
even more expensive, with at least two live-in carers required. conditions. The Act provides an indication of how each condition
How medical aid works should be covered, based on proven practice and affordability.
Many people think medical aid is the same as insurance, but that cover admission for initial diagnosis and management of acute
is true in only the most superficial way. Both involve monthly psychotic symptoms for one week, but the majority of dementia
payments for a level of cover for when things go wrong, but that cases are irreversible, and will not respond to treatment within
is where the similarity ends. a week. This is a murky area, and vagueness of terms is more
Insurance involves paying a risk-based premium to an insurance often interpreted in favour of the scheme, not the member.
company, which is a profit-making enterprise. The insurance For the listed chronic conditions, schemes are required to cover
company decides the cost of the premium based on the client’s medication, doctor’s consultations, and tests, according to the
risk factors, including such things as age, lifestyle, pre-existing Council for Medical Schemes. The only disease listed that has
medical conditions, and even hazardous hobbies or occupations. an obvious link to dementia is Parkinson’s. Alzheimer’s disease,
Medical aids, on the other hand, are non-profit schemes in which is the most well known cause of progressive dementia, is
which the members pay the same contribution regardless not listed.
of their lifestyle, age, occupation or pre-existing conditions. Some medical schemes cover medication for Parkinson’s and
‘Treatable dementia’ is a PMB, and the schemes are required to
The exception to this is that people who start contributing to Huntington’s diseases under its chronic illness benefit, but they
medical aid only after the age of 35 pay a pro rata late joiners don’t cover frail care, full-time nursing, or any care that does not
penalty. This is because medical aids are based on the concept of require a trained medical person.
cross-subsidisation in which the younger members, who are
usually healthier, subsidise the older members,
who usually need more medical care. In
turn, when they age, they are subsidised
by a new group of younger members.
Financial broker Ivor Jones explains
that keeping a medical aid scheme
liquid is a delicate balancing act,
because they can’t spend more
than the members’ contributions.
So, they may have to limit what
they can cover in order to not
overspend.
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What medical aid schemes
provide
The Act does provide for palliative care, which is the
management of terminal conditions such as cancer, with
schemes required to cover ‘comfort care, pain relief and
hydration’. Some schemes also cover psychosocial support and
nursing care but there is a limit on the amount it will pay out.
More to the point, as dementia is not a terminal disease, it is
not covered under palliative care.
Jones says that he is not aware of any scheme that will cover
day-to-day nursing or frail care, but he points out that there are
some benefits that medical aids provide that people may not be
taking full advantage of. He explains: ‘If you are on a hospital
plan, all your out-of-hospital costs will be paid out of pocket.
With a comprehensive plan with above-the-threshold benefits,
there is no limit on your doctor’s consultations, for example
when you need to see a neurologist for Alzheimer’s treatment.
Your medication will also be covered, although there can be a
Each medical aid scheme offers different limit on that. You have to ask if you’re on the correct plan with
benefits or health services to its your medical aid.’
members, and it is notoriously difficult to wade through the details, sub-clauses, Bottom line
exceptions, exclusions, and special Medical aid schemes are not required by law to provide all
conditions. However, there are some the care that dementia patients need, and in the course of
services that they are required by law researching this article we did not find a medical aid scheme
to provide, under the Medical Schemes that covers dementia care or frail care adequately. Both are very
Act 131 of 1998. These are referred to expensive, and it is therefore necessary to consider alternative
as prescribed minimum benefits (PMB) options for financial support, such as unit trusts or annuities.
Rehana Dada