What Does Health Insurance Actually Cover?


Jade Poole

What Does Health Insurance Cover

We dig into the details of health insurance, what it is and more importantly what it covers. Here’s a hint - it’s so much more than just a hospital plan.

What is health insurance?

Before we get into what health insurance covers, let’s first explain what health insurance is. Health insurance is an affordable alternative to medical aid. It gives you the same access to private healthcare, but compared to medical aid, health insurance works a little differently.

In exchange for a monthly premium, your insurer will help cover the costs of day-to-day healthcare checks, as well as accidents and illness.

What many people do not realise is that health insurance is so much more than just a hospital plan.

One of the main differences between medical insurance and medical aid is that health insurance outlines set limits and benefits to your cover. Meaning you know EXACTLY how much cover you have and what you can claim for.

How does health insurance work?

The first thing you need to know about Oneplan Health Insurance is the different benefit divisions:

  1. Health cover: doctor visits, medication, x-rays, dentist visits, eye doctor visits, blood tests
  2. Hospital cover: Illness, accidents and dread disease
  3. Maternity cover: pre-birth and delivery

With Oneplan Health, we front you with the cash you need BEFORE you see the doctor. You can find out more about this amazing claims system here.

Below, we break down what cover each section of our health insurance includes.

1. Health cover

Doctor visits

●        Visits to your doctor, treatments, tests and procedures in rooms based on your cover limits

**A limit is the maximum amount of money we (that’s us) may pay you for a claim or the amount stated on your invoice.)


  • Prescribed medication
  • Baby and child immunisations
  • Flu vaccinations
  • Chronic (ongoing) medication (including ARVs)
  • Doctors who give you the medication themselves


Radiology (X-rays)

●        X-rays, sonars, ultrasounds, mammograms, bone density, barium meal or enema 

●        CT and MRI scans, other imaging tests and scans

Pathology (Blood tests)

●        Tests to examine your blood, tissue, bodily fluids, smears, swabs and biopsy samples etc.

Dentist visits

●        Fillings, extractions, fluoride treatment, root canal, dentures (false teeth), crowns, bridges

●        X-rays done in the dentist’s rooms

Eye doctor visits (optometry)

●        Glasses (frames and lenses), contact lenses, tinting of lenses

**This cover works in a 24-month cycle where you can only claim every 24 months according to your cover limit, after the initial waiting period of 12 months.

2. Hospital Cover

Casualty illness

●        Treatment and procedures in casualty for life-threatening conditions

**These are emergency treatments for illnesses that do not require overnight hospital stays. Casualty refers to the emergency department in a hospital.

Casualty accident

●        Treatment and procedures in casualty for injuries that require immediate treatment and are life-threatening (life-threatening means that if you do not get treatment within an hour of the issue, it will result in permanent damage to you)

**These are emergency treatments for accidents that do not require overnight hospital stays.


●        Treatments and procedures that need hospital admission

**An illness is a disease or sickness that started after your cover began.


●        Treatments and procedures that require hospital admission

●        Re-admission within 6 months for the same or related accident will be deemed as one event and covered under the same cover

**Accidents are the stuff you didn’t see coming - such as when you are involved in an accident like a car crash and you need to immediately be seen by a doctor.

What’s the difference between an accident and an illness?

An injury is a physical cut, bruise, burn, sickness or disease or some kind of harm done to your body that was caused by an accident.

An illness is a disease or sickness that started after your cover began.

If an illness is the result of an accident, it will be covered under illness and not accident cover. For example, if you are in a car accident and contract pneumonia in hospital - this illness will be covered under illness cover.

Dread disease (serious diseases)

●        Heart attack, Coronary artery disease requiring surgery, Heart valve replacement

●        Surgery to the aorta/aneurysm, Stroke, Cancer, Major organ transplant, Brain tumours


●        Injuries that result in you not being able to use your limbs or permanent disability that occur within 12 months from an accident

3. Maternity Cover


●        Gynaecologist or midwife visits

●        Sonars done in the practitioner’s rooms

**These are appointments and medical care that take place before your baby is born.



●        Home and or midwife deliveries, water birth

●        Emergency or clinically indicated caesarean section

●        Mother and newborn covered under the same cover (one limit)

Additional benefits to Oneplan health insurance

What is health insurance

Funeral cover

All of our health insurance plans include funeral cover.

If you and your family have health insurance with us when a family member dies, we will pay you a lump sum based on your chosen health care plan. 

Cover for your family members too

If you have a health insurance policy with Oneplan then we also allow you to cover the health of your family members too! With us, we will let you insure up to 6 people on your health insurance policy (you plus 5 family members).

Ambulance and Emergency Services

At Oneplan, we have a 24-hour dedicated line for medical assistance. In the event of a life-threating emergency, you will be transported by an ambulance to the nearest hospital.

Team of nurses to chat with

Have any health concerns you want to know more about? We have a dedicated team of nurses readily available for you to chat with using the Oneplan smartphone app.

Yours in hassle-free health insurance,


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