Healthcare for the consumer

01 June 2008 Adrian Hofman, Health & Accident

It is becoming increasingly clear that many healthcare advisors are not familiar with the various aspects of healthcare cover offered by various parties. It is crucial that advisors understand the complete picture, if they are to provide their clients with best advice.

When a healthcare advisor offers advice regarding the cover offered by the various insurance products available in the market, the advisor should be aware of the cover offered by various government and private institutions.


The first aspect of cover for all South African citizens is the healthcare offered by the government through the Department of Health. Although the level of service may not be adequate, all citizens are supposed to have access to healthcare services – primary as well as hospital cover. These services will vary in accessibility and level of service from area to area.

The cover offered by the Road Accident Fund (RAF) may be considered to be the next level of cover, since even unemployed persons would enjoy this cover, provided they incur an injury as per the qualifications of the RAF. Accessibility and the payment of benefits from the RAF may be in question and certain parameters apply; but the cover applies every person who purchases petrol/diesel, thereby contributing towards this fund.

The fund is hopelessly behind in the processing and paying of valid claims. The RAF announced in March 2008 that they had a backlog of claims amounting to R27 billion.


The following aspect of cover would be that of the Occupational Health and Safety Act, which affects all employed persons. The cover extended by this Act includes any health events (illness or injury), including all health costs related to the injury or illness, which occur as a direct result of the environment or work place of the employed person. These costs may include treatment at private healthcare facilities.

Public and Passenger Liability

Two further aspects of healthcare cover for either employed persons or persons who insure their own home or motor vehicle, are those of Public Liability and Passenger Liability, respectively.

All healthcare costs related to an injury which occurs under the definition of a Public Liability incident is covered up to the specified limit of the insurance policy terms. The same applies to the cover offered under a motor vehicle policy under the Passenger Liability section.

In terms of both Public Liability and Passenger Liability, the onus is on the affected party to prove that the insured party was negligent at the site (place of work or home) or that the insured party was irresponsible in their driving behaviour. These two aspects of cover are underutilised in the South African market and there are few successful claims under these categories of insurance.


Finally, there is private health insurance which generally includes medical aid, health insurance, travel insurance and disability insurance. These forms of cover would typically only be available to employed persons who are earning an income, which permits such cover to be purchased.

Medical schemes are coming under increasing pressure to offer comprehensive cover, yet the annual increases they are permitted to levy are being legislated. As a result, medical schemes will begin to consider which areas of the cover they offer overlap with the cover offered by other organisations, whether they are government run or other public insurers.

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