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SA's No 1 Insurance Blog

A lot of people seem to be asking the same question: “Isn’t there something better than medical aid out there?”

The simple answer is no, and we’d never recommend cancelling your medical aid either.

Here’s why:
All a medical scheme is, is a group of people pooling together their contributions to pay everyone’s medical costs. It works because the healthy sponsor the unhealthy.

But what would happen if all the healthy members left, leaving the sickly to pay their own bills?

All it takes is for a bunch of people to decide they’re sick of paying for something they don’t use, and then the scheme goes down the tubes. This was a major risk.
Long term insurance companies saw a gap and started to compete with these medical aid schemes, and so finally, the government stepped in and drew a line in the sand.
Insurance companies weren’t allowed to compete.

But short term insurance companies identified a few gaps in the market which weren’t being addressed by medical aid schemes. OnePlan is one such company.

Previously we looked at the health cover benefits offered by OnePlan.

Today we take a look at each of their 8 hospital cover benefits.

Emergency Illness and accident cover

To me, any illness is an emergency. Question is, what does OnePlan consider an emergency?

The OnePlan definition is:

If you require urgent medical attention deemed to be life threatening (As determined by the OnePlan emergency call centre), and which cannot wait for a normal consultation at your doctor.

The benefit they’re willing to pay appears below. By the way, the smiley green face means happy. The red face means furious, and the purple face means surprised, as in why is the cover so low.

OnePlan Emergency Illness

Three things to be aware of:

  1. Pre-existing conditions are not covered.
  2. There’s also an excess of 15% of the claim amount payable to OnePlan.
  3. There’s a 90 day waiting period from inception of policy before being allowed to claim under this benefit.
  4. Emergency accident cover, on the other hand, has no waiting period

Accident Cover

This is all about being hospitalised as a result of an accident.
You’re also covered for up to 6 months after the date of the accident for any injury relating back to the accident, which is nice.

OnePlan Accident Cover

Two things to consider:

  1. R500 excess per claim which becomes 15% of the claim amount if it’s because of a contact sport
  2. Contact sport injuries are also excluded for 12 months from start date.

Illness in Hospital

This is the big one. What will they pay if I end up in hospital and needing an op?

The OnePlan definition for this is:

An event requiring hospitalisation for an illness or operation that is not related to a pre-existing condition

OnePlan Illness in Hospital

The following illnesses are excluded for 12 months:

  • Tonsillectomy
  • Grommets, adenoids, ear and nasal surgery
  • Hernias
  • Pregnancy complications
  • Certain gynaecological conditions, hysterectomy amongst others
  • Kidney and gall stones (including removal of gall bladder)
  • Ulcers, gastroscopies and all the other ‘scopies’
  • Spinal procedures and joint surgery

And these illnesses are not covered at all:

  • Dentistry
  • Pain control, and
  • Arthroscopies

Be aware of:

  • The 90 day waiting period before allowing a claim
  • The 15% excess if you claim between months 4 and 6
  • 5% excess after month 6

Dread Disease Cover

Newly diagnosed dread diseases are covered for up to 12 months after the diagnosis. Existing dread diseases have waiting periods. The amount paid will be up to the full amount insured under your plan. If the same disease reoccurs after a 6 month recovery period, then you may claim again which is a really nice benefit to have.

OnePlan Dread Disease

The following dread diseases are covered:

  1. Heart attack
  2. Coronary artery disease requiring surgery
  3. Heart valve replacement
  4. Surgery to Aorta
  5. Stroke
  6. Cancer
  7. Acute Kidney failure
  8. Major organ transplant
  9. Brain tumour

Be aware though:

  • There’s a 6 month waiting period
  • Pre-existing dread diseases are excluded for 12 months. If they were diagnosed within 24 months of starting the policy, and re-diagnosed within the first 6 months of the policy, they could be excluded completely
  • Up to 3 dread disease claims for the same disease will be allowed per dependent

Natural Birth and Emergency Caesarean

No explanation really necessary here. Where you have elected to have a caesarean, this is covered up to the same amount as for the natural birth.

OnePlan Childbirth

Be aware of:

  • 12 month waiting period before they will allow a claim
  • The excess payable by you is 10% of the claim amount
  • Natural birth, water birth, and midwife deliveries are all covered
  • If the baby is born during the first 12 months that this policy is active, then OnePlan will not cover any complications relating to the birth.
  • After the birth, the new-born may be added if given a clean bill of health by the hospital. This must happen within 30 days of birth.

Accidental Disability

This section covers permanent disability only, and generally relates to the physical loss of a limb.

OnePlan Accidental Disability

The following losses result in a 100% payout:

  • Loss of 2 limbs
  • Loss of both hands or all fingers and thumbs
  • Total blindness
  • Total loss of hearing
  • Paralysis
  • Being permanently bedridden

No waiting periods apply.

Family Death Cover

This is standard enough with a distinction made between natural death and accidental death.

Natural death has a waiting period of 90 days and is caused by:

  • Disease
  • Age
  • Hospital Operation

In the diagram below the arrows point to the plans offering the same benefits. The Health plan offers zero benefit here. The benefits payable under accidental death are exactly the same as those payable under natural death.

OnePlan Family Death

So which plan works out best?

Well this all depends on your needs. To me the ‘illness in hospital’ is a biggy. If I can’t afford medical aid for whatever reason, then the most cover I can afford is next best.

For this reason, the Premier option works best:

  • Illness in hospital – R170, 000 versus their next best option of R96, 000
  • Dread disease – R340, 000 versus second best of R283, 000
  • Monthly cost for a single person in 2016 – R1, 340

  What’s nice about Oneplan?

I like the options it opens up for you:

  • It allows you the option of downgrading your medical aid and topping it up with benefits not available on your medical aid. Choosing a medical aid plan can be a minefield. There are cheaper plans offering the same level of ‘in hospital’ care as the more expensive plans.
  • Things like dread disease cover and funeral benefits aren’t offered by medical aid schemes.
  • And remember that any payout you receive from OnePlan is not determined by what your medical aid pays out for the same operation. Any shortfall not paid by your medical scheme can be covered by your OnePlan policy.

Think of OnePlan as a top up to your existing medical aid. But don’t make this decision without first consulting your health schemes broker.

Until next time.

The InsuranceFundi Team