What is health insurance?


Flexicare is a health-insurance product. What does this mean? And how is signing up to health insurance different from joining a medical aid? We explain all this and more! You're also about to find out how Flexicare gives you access to high-quality, affordable private day-to-day healthcare cover.

Discovery Health - in partnership with Auto & General - recently launched Flexicare, an innovative and affordable health-insurance product for South African residents. With Flexicare, they can access high-quality, affordable private healthcare for their day-to-day health and medical needs.

"The terms 'medical aid' and 'health insurance' are often used in place of each other," says Nonkululeko Pitje, Head of Employee Health Solutions and Group Client Solutions at Discovery Health. "However, there are big differences between them."

"Flexicare is not a medical aid but a health-insurance product," she explains. "It's designed for South African residents who can't afford to belong to a medical aid but who want access to, or cover for, private healthcare for their day-to-day needs. And, they want to pay for this cover themselves. Flexicare is part of Discovery Health's vision to expand access to affordable, high-quality healthcare to all people living in South Africa."

- Now, through Flexicare (which is underwritten by Auto & General), this innovative health-insurance product is available to the public - at highly competitive monthly fees from only R350.

So, what exactly is health insurance?

"As mentioned, Flexicare is a health-insurance product, not a medical aid," says Nonku. "It's not supposed to be a replacement for a medical aid, which offers broader cover. Rather, it's an affordable way to access private day-to-day healthcare."

- Read on to see the benefits you have access to with Flexicare.

"For a fixed monthly amount, health insurance covers day-to-day medical expenses such as a consultation with your GP, medicine and basic dentistry," Nonku explains. "The health-insurance company pays the healthcare provider directly, so you don't have to worry about the cost."

These are the main features of health-insurance products

Health insurance is governed by long-term and short-term insurance laws and not by medical scheme legislation. This means it does not have to include treatment for certain conditions on the Prescribed Minimum Benefits list (also known as PMBs).

Waiting periods

Similar to medical aids, a health-insurance product can come with waiting periods for:

  • Healthcare services related to specific conditions or treatment
  • General access to benefits

This means that you won't be able to claim for medical treatments for a certain amount of time after your health-insurance cover starts.

Some health-insurance products might not be available to people who are over a certain age.

Contributions and payments

The monthly contribution for health insurance is usually lower than for cover on a medical aid. That's because medical aids give you access to a wider range of benefits and cover options than you would get with a health-insurance product.

Health insurance can include other types of cover, such as personal accident disability cover, death cover and funeral cover. Medical aids do not offer this. However, these extra benefits may increase your contributions.

Health insurance pays out a set amount for your medical expenses (either to you or to your healthcare provider). The amount won't differ, no matter what type of treatment you have or which healthcare providers you use.

To keep health-insurance products affordable, they focus mostly on out-of-hospital, day-to-day healthcare expenses such as going to your GP, getting medicine, and basic dentistry. Usually, they have strict rules about using specific healthcare providers in their network. If you don't use these providers, then the health insurance won't pay out.

Some health-insurance products include a fixed payout for being stabilised in hospital in an emergency.

Let's look at how medical aids work

Medical schemes are governed by the Medical Schemes Act ("Act"). Under this Act, all schemes must pay for a basic level of care for 27 chronic conditions and 270 diseases. These are called Prescribed Minimum Benefits, or PMBs.

As a member of a medical scheme, you pay a monthly contribution for financial cover for your medical expenses. (The amount you pay depends on the medical plan you have chosen.)

These could include expenses for a doctor's visit, nursing, surgery, optometry, medicine and hospital stays. The healthcare services covered depends on your chosen medical plan.

If you're hospitalised, your medical scheme will normally make a payment directly to the hospital.

You may have to use healthcare providers who belong to your medical scheme's network - again this will depend on the medical plan you have chosen.

Contributions to medical aids are deductible for tax purposes.

What does Discovery Health Flexicare give you access to?

"Our research and experience have shown the importance of creating an easy-to-understand product - one that ensures people never have to pay out-of-pocket or face hidden costs," says Nonku.

"Also, to make sure that as many people as possible can access Flexicare, our healthcare provider network includes doctors in the major metros. We are expanding on this network daily."

1. Form only R350 a month, Flexicare gives you access to:

  • Unlimited GP consultations: This includes online consultations with a doctor in our network who is allocated to you. Members don't have to make co-payments for GP consultations.
  • Prescribed medicine, chronic medicine and over-the-counter medicine.
  • Basic dentistry: Cover for dentist visits, fillings and tooth removal by a network dentist.
  • Basic optometry: Cover for one eye test every year and one pair of glasses every 24 months from a healthcare provider in the optometry network.
  • Blood tests and X-rays are covered when requested by a network GP.

2. There is also the option to access trauma cover for hospital:

An optional trauma benefit covers you for emergency private healthcare services at any hospital facility.

There are two choices under this benefit:

  • Cover of R400,000 for each hospital admission: an extra R160 a month.
  • Cover of R1 million for each hospital admission: an extra R224 a month.

Accidents and emergencies that are covered by the trauma benefit include:

  • Burns
  • Head injuries
  • Chest injuries or severe fractures caused by a fall
  • The loss of an arm, hand, leg or foot
  • Near-drowning
  • Poisoning or a serious allergic reaction that may cause death
  • Injuries resulting from a crime, sexual assault or a car accident, or an injury at work.
Health insurance improves access to private healthcare

"In summary, although medical aid membership is valuable for people wanting to access private healthcare, not everyone can afford it," says Nonku. "Health-insurance products solve this by offering cover for high-quality, affordable private healthcare for a fixed monthly contribution that is usually lower than contributions to a medical scheme."

"Our Flexicare offering is one of the many ways in which Discovery Health ensures there's a product to suit every person's financial and healthcare needs," she adds.

Find out more

For more information about Flexicare, visit our website.



Katharine Child. 11 April 2022. Health insurance policies thriving despite ongoing regulatory impasse. Business Day. P3.



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