Medical related terms

  • Acute condition
    An acute condition is a self-limiting condition that disappears after treatment e.g. appendicitis or tonsillitis. An acute condition is generally of shorter duration and is characterised by relatively fast recovery after treatment.
  • Acute medication
    Acute medication is the type of medicine a GP will prescribe if the medicine is intended to treat a short-term illness and relieve symptoms. For example, if you developed a chest infection that required a course of short-term antibiotics for treatment.
  • Broker
    A financial intermediary who acts on behalf of members or employer groups in return for commission that is paid by the medical scheme.
  • Chronic condition or illness
    A chronic illness is a life-threatening condition that requires on-going treatment e.g. diabetes and asthma.
  • Chronic medication
    Medication prescribed by a medical practitioner for an uninterrupted prolonged period of time. This medication is used for a medical condition that appears on your medical scheme’s list of approved chronic conditions. Cover can be limited to certain brands or generic medication.
  • Chronic medication formulary
    A formulary is a list of medicines used by medical schemes to manage chronic medicine benefits. Your prescribed chronic medicines will be covered according to a set formulary.
  • Closed medical scheme
    A closed medical scheme is one that is only open to a specific profession, company employees, union or association.
  • Community rating
    In terms of legislation, all members of a medical scheme option must pay the same contributions and cannot be asked to pay more due to age or ill health.
  • Continuation members
    Principal members of restricted medical schemes are entitled to remain on the scheme after retirement even if the employer no longer pays the contribution. In the event of the death of the principal member, the dependants will still be covered by the scheme.
  • Co-payments
    A co-payment is a portion of the bill for which the member is responsible. Some options have co-payments for certain procedures meaning that the member needs to pay the designated amount when receiving treatment for that particular procedure. The term co-payment can also be used to describe the member’s portion of the bill if the scheme/option only covers treatment at a certain % and the provider charges above that %.
  • Deductible
    A set rand amount that must be paid upfront by the member for a defined list of procedures.
  • Dependant
    In order for members to qualify as dependants, they need to be the main member’s spouse, child or financially dependent on the main member (and be able to provide proof if necessary).
  • Designated service provider
    A healthcare provider or group of medical service providers selected by the scheme as a preferred provider/s from whom services must be obtained for members to enjoy appropriate treatment and lower or no co-payments.
  • Emergency medical condition
    The sudden and at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunctions of a bodily organ or part or would place the person’s life in serious jeopardy in accordance with the scheme’s protocols.
  • Exclusions
    Some medical conditions and procedures may be excluded from medical schemes e.g. cosmetic surgery and self-inflicted injuries.
  • Formulary
    A formulary is a list of medicines used by medical schemes to manage medicine benefits.
  • Generic medication
    A generic medicine is a drug product that is comparable to brand/reference listed drug product in dosage form, strength, route of administration, quality and performance characteristics, and intended use.
  • ICD (International Classification of Diseases and related problems) Codes
    The inclusion of ICD 10 codes from healthcare providers to medical schemes has been a mandatory requirement since January 1st 2005. Every medical condition and diagnosis has a specific code, called the ICD 10 code. These codes are used primarily to enable medical schemes to accurately identify the conditions for which you sought healthcare services. This coding system then ensures that your claims for specific illnesses are paid out of the correct benefit and that healthcare providers are appropriately reimbursed for the services they provided.
  • Late joiner penalty
    The Medical Schemes Act makes provision for schemes to apply a late joiner penalty to members over the age of 35. Depending on the number of years that you have not belonged to a registered South African medical scheme over the age of 21, the late joiner penalty is calculated as a percentage of your monthly contribution and will be added to your monthly contribution.
  • MMAP (Maximum medical aid price)
    This is the maximum medical aid price that your scheme will pay for the cost of generic medicine, where a generic alternative for branded medicines does exist. Only the cost of the generic equivalent is covered.
  • Network options
    These are options that are in most cases income based, making them affordable for the individual earning a lower income. The medical aid scheme designates certain hospitals, doctors, optometrists, chronic providers and dentists. The member must make use of these designated providers in order for treatment to be covered by the scheme.
  • Occupational health product
    This is an occupational health solution designed for the South African labour market to keep employees who were previously excluded from any form of private healthcare, healthy and productive at work. Please note that this is not a medical scheme.
  • Open medical scheme
    An open medical scheme is open to all members of the public.
  • Pathology
    Pathology is the medical specialty concerned with the study of the nature and causes of diseases. A pathology lab will analyse any blood samples sent by the doctor or medical practitioner to determine the cause of a medical problem.
  • Pre-authorisation
    Hospital admissions for non-essential or non-life threatening procedures need to be authorised by the medical scheme prior to the member being admitted. Pre-authorisation is the process of informing the medical scheme of a procedure prior to the event and obtaining the approval.
  • Pre-existing condition
    A condition for which a member has received medical advice, diagnosis, care or treatment was recommended within the 12-month period prior to application for membership to a medical scheme.
  • Prescribed minimum benefits (PMBs)

    This is a list of 270 treatments plus 26 chronic diseases, for which all medical aid schemes in South Africa have to provide cover in terms of the Medical Schemes Act.

    It also includes the following 26 chronic diseases:

    Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, Chronic Renal Disease, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Crohn’s Disease, Diabetes Insipidus, Diabetes Mellitus Type 1 & 2, Cardiac Dysrhythmia, Epilepsy, Glaucoma, Haemophilia, HIV / AIDS, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus and Ulcerative Colitis

  • Provider
    A provider is the term used to include a General Practioner Specialist, Dentist, Optometrist who “provides” a service as part of the medical cover.
  • Radiology
    Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualised within the human body.
  • Rejection codes
    A list of codes normally reflecting on the remittance advice indicating reasons for any payment discrepancies.
  • Restricted medical scheme
    A medical scheme that only employees from a particular employer or affiliate organisation may belong to.
  • Restrictions
    Depending on a new member’s risk profile, they are sometimes subject to underwriting limitations. Restrictions can take the form of late-joiner penalties, waiting periods or exclusions.
  • Roll-over benefits
    Unused medical savings that are carried over from one year to the next.
  • Specialist
    Medical practitioners who offer specialised products or services not offered by general practitioners (GPs) are called medical specialists. A specialist is more qualified to give an accurate diagnosis of a complex condition.
  • Waiting periods
    When a member joins a medical scheme there is often a waiting period before a member can claim for certain benefits. The waiting period will be a specified period of time applicable from when the date the member joined the medical aid. There are often two types of waiting periods that can be imposed, a general waiting period: during which no claims will be paid, and/or pre-existing condition exclusions.
  • Waiting period  condition specific
    Depending on your previous medical history, a medical scheme may impose a waiting period of up to 12 months from the inception date of your membership for any pre-existing conditions. No benefits will be paid out for any costs associated with this condition.
  • Waiting period - general
    A scheme will normally have a three month waiting period on benefits for new members. No benefits are paid out during this period, not even from a Medical savings Account (MSA) except for procedures that are covered within the Prescribed Minimum Benefits (PMB) as prescribed by the Medical Schemes Act.