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. The issue has now attracted the attention of the National Consumer Commission who feels that medical schemes discriminate against pregnant women (1).
No Cover for Already Pregnant Women
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 only to then leave the scheme shortly after childbirth. 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.
Now most medical aids in South Africa do not cover pregnancy and delivery costs for already pregnant women. You will still be accepted as a member of the medical scheme if you join after falling pregnant but your pregnancy and delivery costs for the current pregnancy is excluded from the cover. Previously there were a handful of medical aids that may have covered pregnant women and pay for the delivery 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. This is because you are not considered as a new member without cover but rather just changing between medical schemes. 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.
In addition, pregnant women who have had medical aid cover within the past 90 days can join a scheme and have their pregnancy covered after a 3 month waiting period. This only applies to instances where there has been a break in medical aid membership not exceeding 90 days.
Costs of Pregnancy
Childbirth costs at a private hospital can be a major financial strain, 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 R20,000 for a normal vaginal birth to over R40,000 for a caesarean section (caesar, C-section). This may depend on your location, the gynaecologist’s fees and whether you have a paediatrician on standby. Doctors who are contracted out of medical aid charge private rates that are higher than the medical aid rate (National Health Reference Price List – NHRPL). 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, it could cost you more than R10,000 per day.
Medical Aid Cover for Pregnancy
Without medical aid cover, you will need to pay an upfront fee which can be between R10,000 to R15,000 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.
Gap Cover for Pregnancy
If you are depending on a hospital cash back plan to cover some of the delivery costs, make sure that you speak to the insurance company underwriting the policy. Some cash back plans have maternity benefits but there is a deferred period meaning that you cannot claim if you are hospitalised for less than 2 days. In addition, hospital cash back plans have a 12 month waiting period and you can only claim thereafter. Instead you should look at medical aid gap cover to fund the difference between what your scheme pays and what your doctor charges.
Consider the difference between what your medical pays a gynaecologist-obstetrician to deliver the baby and what many doctors charge. The medical aid rate is about R2,600 (2013 rate) and many gynaecologists will charge you around R10,000. That is a shortfall of some R7,4000 which has to come out of your pocket. If you are going the C-section route then an anaesthetist may charge you around R3,500 whereas your medical aid will only pay about R1,800 (2013 rate). Another R1,700 shortfall. And remember that it is not only the mother than needs medical care. Paediatricians have varying rates for looking after you newborn baby, let alone if complications arise. These days gap cover just makes financial sense if you have a medical aid.
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.