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Medical scheme rules can be confusing, and the wrong assumption can cost you at claim time. Here are straight answers to the questions members ask most, from cover gaps to dispute resolution.
Medical schemes typically only pay a portion of hospital and specialist costs - often based on a fixed scheme rate, not what the provider actually charges. GAP cover pays the difference between what your medical aid pays and what you're actually billed, so you're not left with unexpected shortfalls after a hospital stay or major procedure. It's worth considering if your medical aid plan has co-payments, sub-limits, or if you use private specialists who charge above scheme rate.
Fund management is the hands-on job of actively investing a portfolio - buying and selling assets to try to grow the fund's value. Asset consulting sits a level above that: it's independent advice on how a fund's money should be structured and managed overall - setting investment strategy, selecting and monitoring fund managers, and ensuring the approach matches the fund's goals and risk appetite. In short: the asset consultant advises on strategy; the fund manager executes it.
Some employers commit to subsidising medical aid contributions for employees after they retire. A PRMSL valuation calculates the total future cost of that promise - essentially, how much the company will owe over time to fulfil it. It matters because this liability must be disclosed in the company's financial statements (per accounting standards), and understanding its size helps the business plan, budget, and manage the risk properly instead of being caught off guard by a growing long-term obligation.
At minimum, comprehensive cover for each vehicle (accident, theft, and fire damage), plus liability cover for damage or injury your vehicles cause to third parties. Depending on your fleet's use, you may also need goods-in-transit cover (if you transport stock), driver/passenger liability, and cover for specialised equipment mounted on vehicles. The right combination depends on fleet size, vehicle type, and how the vehicles are used day-to-day, this is exactly the kind of thing worth a quick consultation rather than a one-size-fits-all policy.
This covers your business against claims from third parties for damage, injury, or financial loss caused by your business's actions, products, or advice. It typically includes public liability (injury or property damage to members of the public), professional indemnity (claims arising from advice or professional services you provided), and product liability (harm caused by something your business sold or made). It protects the business from legal costs and damages if a claim is made against it.
We're independent. That means our recommendations aren't influenced by ties to any single insurer or product provider - we assess the market and recommend what genuinely fits your needs and budget, not what earns the highest commission or meets a sales target.
FAIS (the Financial Advisory and Intermediary Services Act) is South African legislation that regulates how financial advice is given. Being FAIS-compliant means we're licensed and authorised to provide financial advice, held to a legal standard of honesty and competence, required to disclose any conflicts of interest, and obligated to recommend products that are actually suitable for your circumstances - not just whatever's easiest to sell. In short, it's a legal safeguard that protects you as the client.
Answers to the questions members ask most, from GAP cover to dispute resolution. Independent, plain-language guidance you can actually use.
A medical scheme is a not-for-profit fund, regulated under the Medical Schemes Act 131 of 1998, where members' contributions are pooled to cover healthcare costs on a defined-benefit basis. Unlike an insurance policy, a scheme cannot be run for shareholder profit, must cover a defined set of Prescribed Minimum Benefits (PMBs) in full, and is community-rated rather than priced according to your personal health risk.
Medical schemes are regulated by the Council for Medical Schemes (CMS), a statutory body established under the Medical Schemes Act. The CMS registers schemes, monitors their financial soundness, sets and enforces the rules around PMBs, and handles member complaints once a scheme's own internal process has been exhausted.
An open scheme must accept any member of the public who applies, subject to the standard waiting-period rules. A restricted scheme limits membership to employees of a specific employer, or members of a specific profession, association or bargaining council, and may only accept people who fall within that defined group.
Open schemes are legally required to accept any applicant and may not refuse membership or charge you more based on your health status or claims history — this is known as open enrolment and community rating, and it's one of the core consumer protections in the Medical Schemes Act. Age is a partial exception: your contribution doesn't vary by age on its own, but if you're 35 or older and haven't belonged to a scheme continuously since turning 21, the scheme can add an age-linked late-joiner penalty to your contribution (see Q7).
PMBs are a legally defined set of conditions — around 270 diagnosis-treatment pairs, 26 chronic conditions on the Chronic Disease List, and all emergency medical conditions — that every registered medical scheme option must cover in full, regardless of how basic the plan is or whether annual benefit limits have been used up. Schemes may direct you to a Designated Service Provider (DSP) for PMB treatment; using a non-DSP by choice can result in a co-payment.
Possibly. Schemes may impose a general waiting period of up to three months, and a condition-specific waiting period of up to 12 months for a pre-existing condition you were treated for or advised about before joining — but PMBs must still be covered in full during either waiting period. If you were a continuous member of another scheme for at least two years, with less than a 90-day break before joining, the new scheme generally can't impose the condition-specific waiting period, though it may still apply the general one (see Q8).
If you have been a continuous member of a medical scheme for at least two years and apply to a new scheme within three months of your cover ending, the new scheme generally cannot impose a fresh condition-specific waiting period, and your existing late-joiner status carries over rather than resetting. It can, however, still apply the standard three-month general waiting period — the important protection is that PMBs must still be paid in full even during that general waiting period. It is worth getting written confirmation of your membership history from your old scheme to avoid disputes.
Start by lodging a formal dispute with your scheme through its internal complaints or appeals process — most schemes require this before anything else can happen, and it's especially important to raise it clearly if the claim relates to a PMB condition, since PMBs must be paid in full. Keep a written record of every submission, reference number and response, as you will need this evidence if the matter has to go further.
If you can afford medical scheme membership, a scheme generally offers broader legal protection - PMBs, community rating, guaranteed acceptance - that a primary healthcare product doesn't provide. These products are best understood as an accessible entry point for day-to-day healthcare, not a like-for-like substitute for a scheme; speak to an accredited adviser about which combination of cover suits your budget and health needs.
Once you have exhausted your scheme's internal dispute process and remain unhappy with the outcome, you can lodge a complaint with the CMS's Complaints Adjudication Unit by email (complaints@medicalschemes.co.za), post, or in person, using their complaint form together with proof that you first raised the matter with your scheme. The CMS aims to acknowledge complaints within six working days and typically resolves them within 120 days of receiving the scheme's response.