IS YOUR MEDICAL SCHEME MAKING YOU SICK ?
Understanding your Medical Scheme (or health insurance) is key to making the most of your benefits and avoiding unexpected costs.
We specialise in helping members understand and navigate their medical scheme and their options
ABOUT ME
I'm
My name is Eugene Gruss.
It's very nice to meet you. Thank you for taking the time to peruse this website.
I have over 30 years medical aid experience. I started my sales and Medical Aid Consulting journey over 30 years ago and I love it. When I started, I had a great teacher and mentor who helped drive my passion and understanding of Medical Schemes/Medical Aids. From both a consulting and actuarial perspective.
I was always an independent broker which gave me the opportunity to learn all the schemes and their different options, and therefore what plan and scheme is best suited for each member.
I have worked at and with some of the larger consulting firms in South Africa, namely NMG Consultants and Actuaries, Sasfin Financial and Advisory Services and others smaller yet impactful firms.
I left medical aid consulting in 2010, because I am a recovering gambling addict and I had a major relapse, and it was a difficult period for me.
The relapse meant I was no longer "fit and proper" and as such I could not give advice anymore.
Today I am proudly 14 Years Gamble Free.
My passion for helping others fully understand their Medical Scheme has never waned.
Over the years, I have received many phone calls and e-mails from past clients asking for assistance with UNDERSTANDING their Medical Schemes. Just last week a company I assisted 15 years ago contacted me to help them.
I was honored and it confirmed what I have known for the longest time; there is a need for members to better understand how medical schemes work, how their chosen option works and have help when problems arise, like rejected claims etc.
During my time away from consulting and offering advice, I wrote a guide "Understanding your Medical Scheme better".
I am confident at least 80% of members problems can be resolved by understanding their scheme options better.
It's important to remember that every person on a medical scheme is assigned a broker and that broker/brokerage gets paid monthly, whether you see them r don't, or even know who they are.
My aim is not to step on anyone's toes, jut to help members better navigate their chosen scheme and plan better to better reduce their frustration and start understanding the scheme better.
This is where the guide "understanding your medical scheme better",
and this website will play a significant role in understanding.
Every few days we will learn a new section.
DISCLAIMER
I am mindful of the legal boundaries of the type of information and advice I can and cannot give.
I therefore do not provide Financial or Medical Aid advice to anyone (at the moment), which aligns with industry regulations (such as those governed by the FSCA and Council for Medical Schemes in South Africa).
Disclaimer This Website is for learning and understanding purposes only-
No specific advice will be given by me.
Only making sure you understand your options better
the Wix Forum.
Minimum Services
What will be covered
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What is a medical scheme?
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Difference between traditional and new generation plans
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How is a plan funding calculated?
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What is considered chronic and acute?
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What is a Late Joiner Penalty- and how is it calculated?
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What is a medical savings account?
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What is a self-payment Gap and how doI keep this under control?
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What is over the counter medication?
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What is meant by the solvency ratio of a medical scheme?
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What is the difference between Managed Options and Managed Care Programs?
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What is a PMB?
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What is covered as a PMB?
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What is meant by a Designated Service Provider (DSP)?
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What is an ICD10 code? or a Nappi Code?
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What is meant by a hospital reimbursement rate?
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What is a network hospital?
And so much more...
The first Medical Scheme in S.A. was established in 1889- by the employees of De beers consolidated Mines.
The money in a Medical Scheme is in a trust and as such can not be touched by creditors
Medical Scheme Facts
The Definition of a Medical Scheme?
In terms of section 1 of the Medical Schemes Act 131 of 1998, the business of a medical scheme means the business of undertaking liability in return for a premium or contribution.
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Note: It does not say ALL the liability
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It is specifically for granting assistance in defraying expenditure in connection with the rendering of any relevant health service either by the Scheme itself or an agreed service provider
In 1967 there were 267 open and closed Medical Schemes in S.A.
In 2011 98 Schemes
In 2026 there are just 71 Schemes ( 16 open and 55 closed Schemes)
Prescribed Minimum Benefits (PMB's)
This is what all schemes have to cover at cost, but claiming is a very grey area. Some studies show that around 58% of PMB claims are rejected by the schemes
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Because Schemes have to cover it, there is a list of medications, protocols and service providers that each scheme sets for PMB claims and treatment.
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any variation will usually result in non-payment and a migraine.
There are just under 10m people covered on private Healthcare in S.A.
These 10m spend 30% more on healthcare then the remaining 84% not on a scheme!!
If you ever wondered why, you need a broker or why you are confused? It is because the top 5 open medical schemes in S.A. have 84 different options to choose from!!!
Largest single claim amount for Discovery Health-
R 9.6m
There are over 400 private hospitals in S.A. and 217 Government Hospitals
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These 217 hospitals service around 80% of the population
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75% of all Dr's (GP's and Specialists) service 20% of the population while 25% serves 80% of the population
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........... Let that sink in when debating NHI
What you will learn...
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How to navigate your chosen scheme and option
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How to deal with and dispute an unpaid claim- We can assist with this
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What is an ex-grata payment
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What questions to ask your broker
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We can assist with brokering services through a 3rd party company
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What is a Medical Scheme
Here you will understand what is a Medical Scheme and the difference between a New Genearion vs Traditional Scheme
What is Take Home medication
Here you will understand what this means and how different Schemes and Plans pay for this. When you leave hospital how much does your scheme contribute towards the medication you take home when leaving hospital.
What is a waiting period
Here you will understand what a waiting period is and how they are determined.
Could be none/3-months general/ 12-month specific or 3-months general with a 12-month specific
What is a Hospital reimbursement rate
Here you will understand what is 100%, 200% and 300% cover in Hospital, and how does it effect you as the member.
Prescribed Minimum Benefits (PMB)
Here you will understand what a PMB is, how does it cover a member, what are the 27 Chronic conditions and 271 diagnosis that a Scheme has to cover
What is a self-payment Gap
Here you will understand what this gap is, how does it grow, and what adds to the gap over the period of the year.
What are the 3 different options to look at:-
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Network or Capitation Plans: Require you to use specific network doctors, hospitals, or pharmacies within a network to get full cover. You will have basic cover- Black and white x-rays, Basic Dentistry - teeth extraction and fillings.
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Hospital Plans: Cover you only when you’re admitted to hospital. Day-to-day expenses like GP visits or medication are not included. 27 Chronic conditions are included.
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Comprehensive Plans: Include both hospital cover and day-to-day benefits such as doctor visits, dentistry, and optometry.
What is a Late Joiner Penalty (LJP)
Here you will understand what the possible penalty is, that a Medical Scheme could impose on a member who has joined a Medical Scheme after the age of 35. From 5% - 75% penalty.
Why do you have a Co-Payment
EVERY FEW DAYS A NEW SECTION WILL BE ADDED TO THE SITE.
HELPING MEMBERS BETTER NAVIGATE THEIR SCHEME OPTIONS.
THERE ARE OVER 35 SECTIONS TO MY GUIDE THAT WE WILL BE COVERED.
A fixed amount to pay out-of-pocket, for certain procedures or consultations. Co-Payments are also imposed to stop "over utilisation, like certain Scopes and x-rays.
What you should know and what to ask your broker
Medical Schemes are complex and hard to navigate.
Especially with the hard-to-understand terminology, coupled with the different options and what is and isn't covered in-hospital.
What is the cover in-hospital - do I have a co-payment. How are PMB's covered in-and-out of Hospital.
How much is my medical savings account and do I have a safety net/above threshold benefit?
ETC...
10 Starting questions:-
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Does this Medical Scheme cover my chronic conditions? (Make a list)
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Why do you recommend the plan you are recommending? (Look at different schemes))
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What cover do I have in Hospital? (100%, 200%, 300% - is it unlimited)
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Am I covered in any Hospital or a Network Hospital? (DSP's or any Hospital)
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What is my Self-Payment Gap or Safety Net. (Learn to manage this and don't make it a challenge to reach it)!!!
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Do you have any planned hospital admissions- discuss this with your broker.
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Are you planning a life changing event in the near future- like having a baby or getting married?
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Choosing Gap Cover and/or Top-Up insurance is important today. (Know how Gap Cover work)
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How much day-to-day benefits/Medical Savings Account do I have & Do I have a safety Net/Above Threshold?
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Does my scheme offer dentistry, Optometry, Radiology, or specialist consultations?
My Guide -"Understanding Your Medical Scheme Better" is for sale for just R100.
Pop me a mail for more details- medical.aids@gmail.com
CONTACT
MEDICAL AID HELP
How To Contact Medical Aid Help.
Please use the email address and not the contact form yet.
For any general or specific enquiries, please feel free to email medical.aids@gmail.com
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