Joining a Medical Aid After Falling Pregnant
Medical aids usually do not cover any procedure or treatment for a pre-existing condition within the first year of joining a scheme. This applies to pregnancy as well and almost all medical aid schemes will not cover the pregnancy and delivery costs for a new member who joins the scheme when pregnant.
While it may be argued that pregnancy is a normal physiological process and not a disease, medical aids have to weigh out the risks associated with covering a person compared to the total contributions. There has been a trend in South Africa for pregnant women to join a medical aid, stay on it throughout pregnancy and a month or two after childbirth, only to then leave the scheme. The total payout for pregnancy and childbirth costs may be more than the member’s total contributions meaning that the scheme has to fund these costs from the pool. Ultimately it is the other long standing and loyal medical aid members who essentially bear the cost of this practice.
Most medical aids in South Africa in South Africa now do not accept pregnant women. However there are a handful of medical aids with a select member base that may cover pregnant women and pay for the childbirth costs. This is changing almost on a daily basis with even these select few schemes now refusing pregnant women.
These schemes are usually restricted meaning that it is not open to the general public. Only workers in selected industries or professionals with university degrees may be allowed to join the scheme. These schemes may either be partly subsidised by a professional body or related organisation or the member is considered as a low risk client who is unlikely to quit the scheme immediately after childbirth. Refer to the List of Medical Aids and Medical Aid for Professionals for information on restricted (closed) medical aid schemes.
If you are switching between medical aids, your new medical aid should cover you fully for the delivery irrespective of what stage of the pregnancy you are in. Ensure that your cover on either your old medical aid or the new one is not inactive while you switch over or you will not be covered for any emergency that can suddenly arise.
Costs of Pregnancy
Childbirth costs at a private hospital can break one’s budget, especially if there are complications like a premature delivery. Apart from the costs of the gynaecologist, paediatrician and hospital charges, your baby may need after care like in a neonatal ICU and this can further strain your budget. If you do not have the funds upfront for a delivery at a private hospital, your options are limited – it’s either a government facility or your family doctor and a midwife delivering the baby at home. There are smaller clinics that cater for childbirth but with the possibility of complications, most expectant mothers would prefer to deliver within a hospital environment.
The cost of giving birth at a private hospital in South Africa can vary from R7,000 for a normal vaginal birth to over R12,000 for a caesarean section (caesar). This may depend on your location, the gynaecologist’s fees and whether you have a paediatrician on standby. Add on the costs of the delivery ward, anesthetics and additional procedures coupled with the hospital stay after delivery and your bill can be staggering. Should your baby need to be kept in a neonatal ICU or on a ventilator, you costs could exceed R20,000 to R30,000.
Medical Aid Cover for Pregnancy
Without medical aid cover, you will need to pay an upfront fee which can be up to R5,000 at some private hospitals. You will then be required to settle the remaining amount once you are discharged. While some private hospitals may be lenient and allow you between 60 to 90 days to settle your bill, most will take legal action if you are unable to pay almost immediately.
Medical aid cover removes this uncertainty and apart from covering you for all the necessary costs, your baby is automatically covered within the first 30 days of life even though you have not added him or her onto your medical aid cover.
With many medical specialists now charging fees above and beyond the NHRPL (National Health Reference Price List), some as high as 300% of NHRPL, cheap medical aid cover will not do. It is important to speak to your medical aid and find out if they cover the doctor’s fees at these rates. If not, you will be paid the NHRPL rate and you will then need to pay the difference from your own pocket.
Hospital Plans for Pregnancy
With more South Africans now opting for hospital plans rather than a full medical aid cover with comprehensive benefits, it is important to familiarise yourself with your plan’s extent of cover. Pregnancy costs like your monthly gynaecologist check up will not be covered in these hospital plans. However, all hospital plans will pay for the delivery and any other costs that you or your baby may incur while in hospital. This however may be restricted to the NHRPL rate.
Hospital medical aid plans should not be confused with hospital cash back plans or hospital insurance. The latter is a form of insurance that will pay you a daily rate if you are hospitalised. This is not a medical aid and private hospitals in South Africa will not accept these cash back plans for your hospital costs. However, they may be useful to subsidise any additional costs that you may incur during this time, like the doctor’s fees that are above and beyond the rate paid for by your medical aid. If you are depending on a hospital cash back plan to cover some of these costs, make sure that you speak to the insurance company underwriting the policy. Some cash back plans have maternity benefits but others might not.
Remember that you should join a medical aid when you are young, healthy and not only when you will need cover in the near future. Medical aids are able to fund medical costs by pooling all the contributions of the members and should not be seen as a way of saving on medical costs by only contributing for a few months.
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