Pregnancy can be a delicate time in a woman’s life. Your body is changing and you want the best possible medical care for you and your baby. Private healthcare is usually seen as the better choice but it is expensive. Medical aid is one of the only options to access private healthcare services in South Africa with medical insurance being the cheaper option with less benefits. If you are already covered and had cover for more than 12 months then your pregnancy will be funded. However, all types of medical cover have criteria about pre-existing conditions, including pregnancy.
Maternity Benefits for Pregnancy and Childbirth
There are two benefits that pregnant women will need when they are on medical aid. First is the pregnancy-related benefits which falls under the day-to-day benefits. This includes regular consultations and scans with a gynaecologist as well as associated blood tests, antenatal (pre-birth) vitamins and any medication that may be needed. There is no need for hospitalisation during the course of healthy pregnancy. Even additional service providers likes a foetal specialist will not be required in a health pregnancy where the foetus (unborn child) is showing normal growth and development.
Medical schemes will only cover this out-of-hospital pregnancy care under a comprehensive medical aid. That is medical aid cover with both a day-to-day and hospital benefit, with chronic care being standard on all medical aid plans. However, if you only have a hospital plan medical aid the your pregnancy-related costs are not covered as there is no day-to-day benefit. Another option for expectant mothers is medical insurance as this type of day-to-day cover usually has maternity benefits on an outpatient basis.
The second type of benefit that a pregnant woman needs is the in-hospital cover which will pay for childbirth. This benefit will include delivery (normal or C-section), mother’s stay in the hospital and the newborn’s stay in the nursery. Operating theatre costs as well as specialist care for baby in a neonatal ICU are also covered. The costs for obstetrician (who is usually also your gynaecologist), paediatrician for baby and any other essential medical services will also be covered by the hospital benefit of your medical aid cover. Few medical insurance plans also provide a hospital benefit for maternity but this is usually limited.
Costs of Private Hospital Delivery
Pregnancy-related costs can vary greatly. It depends on the number of times the expectant mother consults with a gynaecologist, the scans that are done during the course of the pregnancy as well as supplements and medication. There may be additional costs if there are complications. Childbirth costs can also vary. Although a medical aid will cover the associated costs, most obstetrician-gynaecologists now charge rates above the medical aid tariff. This may be as high as 300% to 400% of the medical aid tariff. The patient is liable for the shortfall between what the medical scheme pays and what the doctor charges.
Fortunately medical gap cover is now available for medical aid shortfalls. This is a short term insurance policy that can pay up to 500% of medical aid tariff. Gap cover is only available for medical aid members and is a separate cover. It is not available to medical insurance members. Gap cover will not pay for the shortfall if the medical scheme does not cover the initial costs according to the scheme’s tariff. For non-medical aid patients, there is always the option of paying a cash rate for a private hospital’s maternity package. This can vary from R30,000 to R50,000 (2020 rates) depending on the private hospital you choose.
Cover for Already Pregnant Mothers
If you are already pregnant before joining a medical aid then your current pregnancy will not be covered. Medical schemes and medical insurers have a 12 month waiting period for pre-existing conditions, including pregnancy and childbirth. This ensures that pregnant women do not join medical aid cover only to use it for the maternity benefits and then terminate membership thereafter. This type of anti-selective practice strains the resources of the medical schemes and disadvantanges its members who loyally contribute to medical aid cover for years without using any benefit.
Women who are already pregnant should not be discouraged from taking medical aid, even though the cover will not apply to the existing pregnancy. Firstly the medical aid will still cover the costs of other medical care and emergency care that may be needed if an accident arises. Secondly the medical scheme may cover your newborn’s medical bills as your baby is automatically covered at birth for a period of time. It is important to clarify what will be covered or not covered with medical aid despite the current pregnancy and other pre-existing conditions excluded during the waiting period.