We set ourselves a challenge to try and find medical cover for one of our readers. Our findings show that medical cover is expensive for many middle-income earners and that a comprehensive hospital plan is possibly the best option.

Elizabeth has three children aged 3, 6 and 9. She has a take-home pay of R15 000 and has to fully cover the costs of the medical scheme as her partner does not have a regular income.

We investigated what cover the larger medical schemes would be able to provide for her, given her income and her need for cover to include her partner and three children. What was clear was that a basic hospital plan was the most affordable option for Elizabeth although for an additional R1 000 – R2 000 per month in most cases, she would be able to move onto a more comprehensive plan.

Fedhealth Maxima EntryZone
Total cost: R2 653 (increases to R2 958 in 2015)

Maxima EntryZone will provide unlimited private in-hospital cover at a network hospital and unlimited cover for 27 chronic conditions. Elizabeth will not however have any medical savings to cover day-to-day expenses such as GP visits.

A great feature of this product is that should Elizabeth or her children be diagnosed with a dread disease or have a life-changing event she could upgrade at any time of the year within 30 days of diagnosis. This means she is not locked into an option and can upgrade should something dramatic happen that changes their circumstances during the year. Fedhealth charges child rates up until the child turns 27, providing they are still studying or are financially dependent on their parents.

Fedhealth covers additional out-of-hospital expenses, including specialised radiology such as MRI and CT scans, and trauma treatment in casualty is also paid by the scheme. This is a great benefit for young families like Elizabeth’s where small children are prone to injuries like fractures and cuts that need stitches.

Under this plan, Fedhealth pays for treatment like physiotherapy, occupational therapy, speech therapy, pathology and general radiology for up to 30 days after leaving hospital.

Upgraded cover:

If Elizabeth wanted cover that included day-to-day expenses, the most cost-effective option from Fedhealth would be the Maxima Saver option for R4 285 (increasing to R4 689 in 2015) which would include R5 472 annually for day-to-day medical expenses.

Momentum Health Custom option
Total cost: R2 755 – R3 366

Elizabeth and her family would receive unlimited hospital cover and cover of up to 100% of Momentum Health rate in hospital. They would also have access to various free screening and preventative check-ups, including dentistry visits, pap smears, and annual health assessments.

The lower monthly premium assumes that Elizabeth uses a hospital within the network and receives chronic medication from a state facility. If she or her children were to suffer from a chronic condition it would be advisable to opt for cover where they receive medication from one of Momentum’s preferred providers although this would increase the premium. So depending on the cost of the medication it may make more sense to pay for the medication from your own pocket or from Momentum’s HealthSaver.

A great feature with Momentum Health is that you can earn money towards health expenses. This means the family could also receive up to R10 800 a year in day-to-day healthcare expenses by maintaining a healthy and active lifestyle. All Momentum Health members have free access to HealthReturns, an incentive programme which rewards a member and adult partner up to R10 800 per year based on their lifestyle and level of activity.

Liberty Medical Scheme: Hospital Select
Total cost: R2974
This would provide Elizabeth and her family with hospital cover at Liberty Medical Scheme’s (LMS) network of hospitals for non-emergency procedures and receive any chronic medications from state facilities. The plan also covers emergency-room visits as well as medical expenses as a result of crime. There is also a preventative core benefit which covers the cost of medical preventative tests such as mammograms, cholesterol tests and prostate tests. LMS also pays for out-of-hospital MRI and CT scans.

Upgraded cover:

LMS Saver Select option for R3706 per month would include an additional R6336 per annum for day-to-day expenses. This is a family option and includes cover for a free dental check-up for each child once a year.  Should any of her children develop a childhood chronic condition, the plan would further pay for medication for eczema, acne, ADHD and allergic rhinitis.

Bonitas BonEssential
Total cost: R3 149

This option would provide 100% cover for hospitalisation as well as covering the Prescribed Minimum Benefits. In addition family members would receive a free flu vaccine and HIV test per year and each child would have one free GP consultation per year.

Discovery Essential Delta Core
Total cost: R3 278

Elizabeth would be covered in full at hospitals in the Delta Hospital Network. For planned admissions at any other private hospital a co-payment would apply. The plan guarantees full cover in hospital for specialists who have a payment arrangement with Discovery, otherwise Discovery pays up to 200% of the Discovery Health Rate for other healthcare professionals. All 27 chronic illnesses that fall under Prescribed Minimum Benefits are included as well as cover for medical emergencies when travelling.

The adviser’s recommendation: Medihelp Dimension Prime 1
Total cost: R2 332

Financial adviser Duncan Barker recommends that Elizabeth considers Medihelp Dimension Prime 1 which would cost her R2 220 as she will only pay for two kids. This will provide full hospital cover as well as R2 250 for doctor visits and R1 060 for medication for the family.

Barker recommends that Elizabeth also includes gap cover with Stratum Gap 500 for R 112 a month.

“This would give her medical cover for just under R2 500 per month and provide vital hospital cover and some savings for those inevitable doctors’ visits with kids,” says Barker.

This article first appeared in City Press