A comprehensive review of National Healthcare Group’s medical insurance: A member’s experience and perspectives

(1) Background and aim of this review:

The ever-increasing high costs of medical aid preclude the vast majority of South Africans from being members of medical schemes. After exiting my parent’s medical aid, as a child-dependent, I went from being an undergraduate/postgraduate student to an unemployed graduate, which meant that medical aid membership was never affordable to me. After several years without any form of health cover, I began to explore the offerings of medical insurance companies, as a cheaper (albeit less comprehensive) alternative to a traditional medical aid. After thoroughly comparing the plans of various medical insurance companies, I settled on a National Healthcare Group (NHG) product, as this company had (and still has) the most cost-effective plans than any other on the market, thereby enabling ordinary citizens to have access to quality private healthcare, irrespective of their socio-economic status.

I have been a member for the past three years, and in this review, I aim to share my experience of this organization, highlighting the immense contribution that they have had in improving my health and well-being. I also aim to share my opinion of how aspects of their medical insurance can be improved upon, to further strengthen their current products and services.

(2) NHG’s medical insurance is instrumental in improving member’s health:

Since signing up as a NHG medical insurance member, I have had the opportunity to have wellness checkups with healthcare professionals, which resulted in me finding out that my health was not as perfect as I had imagined that it was. Firstly, through pathology tests, which were instructed by my network general practitioner (GP), I found out that I have hyperlipidemia, which is a silent killer and strong risk factor for cardiovascular disease. I’ve since been on treatment for it, which (depending on one’s selected plan) are covered by NHG’s chronic medicine benefits.

I also utilized the optometry benefit, to have my first comprehensive eye test done. I honestly assumed that my sight was fine, and only did the test for the sake of making use of the available benefit. It turned out that my vision wasn’t perfect after all, and due to astigmatism, I was prescribed spectacles, which was paid for in full by NHG.

What was even more concerning about my eye test, was that the optician detected large cupping of the optic nerve in both my eyes. Cupping is a symptom of glaucoma, which is a hereditary disease that damages the eye’s optic nerves, and can lead to blindness. This characteristic was even more concerning to me because my father has glaucoma, which resulted in him becoming blind in one eye a decade ago. Using my medical plan’s specialist visitation benefit, I consulted with (and received diagnostic tests by) an ophthalmologist, who thankfully confirmed that I do not have glaucoma. This was such a relief to me, as I see the daily struggles that this disease has had on my father, and thanks to NHG, I now have peace of mind that this is not a generational curse that I have been handed, and that I can use the optometry benefit in the future, to pro-actively monitor any changes in my eyes.

I have also made use of the annual flu vaccine benefit, as well as the dental benefit twice yearly, which are useful added benefits.

(3) NHG provide a generally seamless service to their members:

To date, I have not had any issues with NHG regarding payments to healthcare providers and refunds that were due to me. They have never questioned my use of the benefits, nor attempted to find loopholes to avoid paying for a claim. My ophthalmologist’s bill was a hefty R2,000, which I paid for in cash, and a mere two days after submitting my claim to NHG, the money was refunded in full into my bank account. Overall, I have found that NHG (and their associated administrators and partners) are extremely efficient. The healthcare provider network is extensive, thus enabling easy access to service providers, irrespective of a member’s geographic location.

NHG’s flagship service, which was created in the advent of the COVID-19 pandemic, is a WhatsApp-based telemedicine service that connects members to an in-house clinical team, thereby avoiding the need for in-person doctor visits (unless clinically needed). I found this service to be remarkably easy and convenient to use, and without excessive waiting times for one to receive assistance. Clinicians readily provide over-the-counter medicine prescriptions, and the resident GP, Dr. Makhambeni, is an absolute pleasure to consult with virtually. All the staff are very helpful and courteous, and the team also includes service consultants, who are readily available to address certain administrative issues and queries that clients may have.

(4) Aspects of the NHG medical insurance that can to be improved upon:

4.1. Whilst NHG offers the most affordable medical insurance products, I believe that the pricing of the plans needs revisiting. The “Day-to-day” and “Premier” options have significantly more benefits than the “Connect” option (namely, specialist consultations, chronic medicine, optometry, flu vaccine, health assessment, maternity scans, accidental death cover, emergency casualty cover, and accidental hospitalization). Furthermore, members on the “Connect” option require screening of symptoms and pre-authorization by the WhatsApp clinical team before they are able to visit a GP physically, whereas the two higher options allow three or six in-person GP visits per year without authorization. Despite these vast differences in benefits, the “Connect” option is 73% of the price of (and only R61 per month cheaper than) the “Day-to-day” plan. So essentially, a member paying just R732 per annum more for the “Day-to-day” plan will get 3 GP visits (valued at ±R1,500), specialist visits (up to R2,060), a flu vaccine (±R100), a health assessment (±R200), optometry benefits (usually around R2,000 for an eye test and spectacles), plus chronic medicine on the formulary (unlimited), 2 pregnancy scans, accidental death benefits, and trauma room stabilization (up to R5,000), if needed. I cannot help but point out the glaring disparity here.

I would implore NHG to look at the total claims they paid for the three plans individually over the past year, and to compare that to the total premiums they received per plan during that period. I am pretty positive that this exercise would reveal that the “Connect” plan has a significantly lower claims-to-premium ratio than that of the two higher-tier plans. If this is the case, as I imagine it is, NHG needs to adjust the premiums of the three plans accordingly (or alternatively, include some additional benefits, such as chronic medicine and optometry, to the “Connect” option), because it currently makes no financial sense being a “Connect” member, and receiving less benefits at a higher relative cost. In this scenario, the “Connect” members (who are likely the lowest-income members of the three plans) are actually the one’s literally and figuratively paying for the lower relative premiums of the “Day-to-day” and “Premier” members, because their higher relative premiums would essentially contribute towards the payment of claims of the higher-tier members, which would be extremely unfair if true.

The “Connect” plan should be NHG’s “poster child” option, since it is the only one of the three that is purely using NHG’s unique selling point of the highly effective WhatsApp clinical line for managed care. Furthermore, it is the cheapest offering, which substantiates NHG’s rationale that private healthcare can be affordable even to the lowest-income groups. Based on what I have described in the previous two paragraphs, the “Connect” plan is at risk of becoming an unattractive proposition to new and existing members and, therefore, this needs to be addressed. Whilst I, as a member, obviously cannot dictate the price of NHG’s plans, I personally believe that a more appropriate price for the options in 2027 (if their benefits remain the same) would be around: R140 for “Connect”, R280 for “Day-to-day”, and R380 for “Premier”. This would create a more fair correlation between a member’s contributions and the corresponding benefits, whilst also allowing for an average 9.7% increase in premiums from 2026, to take into account medical inflation and to ensure the long-term sustainability of NHG.

4.2. NHG has a beautiful and simplistically designed mobisite available for their members. However, the “My usage” section has been non-functional for a long time now. This needs to be fixed, so that members can visualize claims from providers in real-time, without having to wait weeks before they see this in their claim statements. Similarly, the downloading function of the “My documents” section has also not worked for some time now, and this needs to be sorted, to enable members to download correspondence from the Scheme.

4.3. As mentioned previously, the WhatsApp clinical line is highly effective, and members can receive help quickly and easily. In stark contrast, NHG’s email service leaves a lot to be desired. Years ago, one could get assistance in 1-2 working days. Some time later, the turnaround time became 2-3 days. This has progressively worsened, and today you would be lucky if you get a response in a week, if at all! This is unacceptable, as a member should not have to wait that long to obtain feedback. Greater effort needs to go towards improving the email support, as the shocking lack of service would chase any prospective clients away, before they even sign up, and it truly brings down the company profile, as evidenced by many negative HelloPeter and Google reviews commenting on this. In the future, staff from the email support department and call centre should rather be located on NHG’s WhatsApp line (serving as the primary client service hub), so that members can get immediate responses to urgent queries on this free platform, without having to make use of the expensive call centre and dysfunctional email service.

(5) Concluding remarks:

Until such time that the National Health Insurance (NHI) reaches fruition (if it actually does at all), more citizens require private healthcare to get their medical needs addressed, and to subsequently alleviate pressure on the already over-burdened public health system. For years, much debate in the medical aid scheme space has centered around developing low-cost benefit options (LCBO’s), with absolutely no tangible results achieved to date. Medical insurance providers, like NHG, are the bridge that links private healthcare to citizens who would otherwise require public healthcare. They have proven that LCBO’s are already present, they work well, and they allow the low-income population (such as myself: an unemployed person) from being completely shut out from having some private healthcare accessibility. It is, therefore, imperative that the Council of Medical Schemes grant permanent (or, at very least, long-term) approval for exempt healthcare insurance providers to continue to co-function in the private healthcare ecosystem, to provide the LCBO’s that medical aid schemes continue to fail to provide themselves!

To NHG, words cannot fully describe the admiration and magnitude of appreciation that I have for you. I am of the firm opinion that you are not a for-profit healthcare insurance company, but rather a group who genuinely cares about improving the lives of people. Thank you from the bottom of my heart for all that you do, and may you continue to flourish and thrive as an organization. I will continue to advocate for you, and without a shadow of doubt, I am a member for life.