How To Claim Preventative Benefits From Your Medical Aid
If your medical aid is anything like most South African schemes, it sets aside money every year for screening tests like cholesterol, blood sugar and HPV checks. Here is how to actually use it before it expires.
Most people pay their medical aid contribution every month and assume their savings account is the only money they have to spend on healthcare. It is not.
Almost every major South African medical aid sets aside a separate amount each year called your preventative benefit. It is meant for screening tests that catch health problems early, before they turn into expensive emergencies. The catch is that almost nobody knows how much they have, what it covers or how to claim it. So most of it goes unused, year after year.
This guide walks you through exactly how to claim it.
Phone your medical aid, ask what your preventative benefit covers, then book your test at Epicentre and bring your medical aid card. We submit the claim to your medical aid for you. You only pay the difference, if any.
What Is A Preventative Benefit, Exactly?
Your medical aid splits your benefits into different "pots" that pay for different things. The three main pots most people will encounter are:
- Day-to-day savings. Money you can spend on whatever you like, from a GP visit to a flu test. Once it is gone, it is gone for the year.
- Hospital benefit. Covers in-hospital care for serious problems.
- Preventative benefit. A separate amount set aside for screening tests, age-related health checks and certain vaccinations. It does not come out of your savings.
Some plans also have a chronic benefit for people with registered long-term conditions like high blood pressure or diabetes, but that is a different topic. We cover that separately on the Epicentre & Medical Aid page.
The important thing about preventative benefits is that they reset every year. If you do not use them by 31 December, they are gone. You cannot carry them over.
What Tests Are Usually Covered?
The list of tests covered preventatively varies between schemes and between plans within the same scheme, but the typical core list is small and well-established:
- Cholesterol and lipid screening
- Blood sugar (glucose) screening for diabetes
- HPV testing (often paired with the cervical screening)
- Prostate-specific antigen (PSA) for men over a certain age
- Cervical screening (Pap smear)
- Annual flu vaccinations
Some plans also cover bone density scans, additional vitamin tests, or expanded screening panels, but those are scheme-specific. The list above is the safe minimum to assume; anything beyond it needs to be confirmed.
Tests you might assume are covered preventatively but usually are not: thyroid function, full hormone panels, vitamin D and B12, iron studies. These can sometimes be claimed under day-to-day benefits or chronic benefits if you have a relevant registered condition, but they are not standard preventative inclusions.
Many people on hospital plans assume they get nothing for day-to-day testing. That is wrong. Even hospital plans include preventative benefits. The amount and the list of covered tests is usually smaller than on a comprehensive plan, but it exists. Always check with your scheme.
The list of preventative tests can expand year to year as schemes update their offerings. Always reach out to your provider to check what your specific plan covers for this year before booking. Which brings us to step one.
The Five-Step Process
Phone Your Medical Aid
Find the customer services number on the back of your medical aid card and phone it. Tell them you want to know exactly what your preventative benefits cover for this year. Ask them to send you the list in writing by email or SMS so you have a record.
Have your medical aid number and ID number ready when you phone. Most call centres will not give you any information until they have verified you are the member.
Check What You Have Already Used
While you have them on the phone, ask how much of your preventative benefit you have used so far this year. They will give you either a rand amount or a list of remaining benefits.
If you have not used any of it yet, you have your full annual benefit available. If you have already used some, you will know exactly how much is left.
Get A Doctor's Referral
For your medical aid to pay for a test under your preventative benefit, you almost always need a doctor's referral. This is true even when the test itself is on the covered list. Schemes use the referral as proof that the test is clinically appropriate for you, not just something you decided to do.
Your GP can write a referral during a normal consultation. Some schemes also accept referrals from a wellness or occupational doctor.
If you want to walk in and pay cash, you do not need a referral at Epicentre. The referral is only required when you want your medical aid to pay. The two are different routes to the same testing.
Book Your Test At Epicentre
Book online or walk into any Epicentre branch in Cape Town, Durban or Johannesburg. Bring your medical aid card and your doctor's referral. If you book online, send us your medical aid details and a copy of the referral when you book so we can check your coverage before you arrive.
We will confirm exactly what your plan pays for and what (if anything) you need to pay out of pocket, before any tests are run. No surprises.
We Submit The Claim For You
This is the part most labs leave to you. Once your sample has been collected, we submit the claim to your medical aid on your behalf. You do not need to fill in forms, scan invoices or chase your scheme for reimbursement.
You only pay the difference between what your medical aid covers and the full price of your tests, if there is any. There is no extra charge for this service.
Skip The Phone Call. We Can Check For You.
If you do not want to phone your medical aid yourself, send us your details when you book and we will check your coverage before any tests are run.
Book A TestThree Things People Get Wrong
1. Assuming "preventative" means "free for anything"
Preventative benefits cover specific tests, not anything you choose to call preventative. If your plan does not list a particular test, it will not be covered under this benefit even if you think it should be. Always confirm before testing.
2. Waiting until December to claim
Many people only think about their preventative benefits when the year is nearly over. By then, it is often too late to book, test, get results and follow up before the benefits expire. Aim to use them by October at the latest.
3. Using day-to-day savings for tests that should be preventative
If you walk into a lab without checking, the test often gets paid from your savings instead of your preventative benefit. That is money you could have spent on something not covered by preventative benefits. Always ask for the test to be claimed against the right benefit.
What If My Plan Does Not Cover Everything I Want To Test?
This is common. Most plans cover the basics like cholesterol and blood sugar but not more advanced testing like full hormone panels or functional medicine work-ups. You have three options:
- Mix it up. Claim what you can from your preventative benefit, and pay out of pocket for the extras.
- Use your savings. Tests not covered by preventative benefit can usually be paid for from your day-to-day savings.
- Apply for chronic benefits. If you have a long-term condition that has not been registered, your testing may be eligible for a different pot of money. We can connect you to a partner doctor who can help apply.
For more on chronic benefits and how to apply, see the Epicentre & Medical Aid page.
The Bottom Line
You are already paying for preventative benefits in your medical aid contribution every month. Not using them is the same as throwing money away. The process to claim them is genuinely simple: phone your scheme, find out what is covered, book a test and let us handle the paperwork.
If you have not done this before, start with a single test. Once you have seen how easy it is, you will probably wonder why you waited so long.
Ready To Use What You Are Already Paying For?
Book a test, bring your medical aid card and let us handle the rest. We will tell you exactly what your plan covers before any tests are run.
