You have just discovered that you are pregnant. The exciting news is marred by the fact that you do not have medical aid cover and you do not want to use a public hospital for giving birth. How can you get medical aid cover? What are your options for accessing private hospitals and doctors without medical aid cover?
It is a reality that many pregnant women in South Africa face on a daily basis – discovering that they have fallen pregnant and do not have the medical aid cover to afford the private healthcare services that they desire. If you do not have the cash at hand to pay for private service providers then your are options are limited. You will most likely have to settle for the public healthcare services.
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Medical schemes do not cover women who are already pregnant at the time of applying for cover for their current pregnancy and childbirth costs. Pregnancy is considered a pre-existing condition. Similarly, medical insurance and hospital cash plans also do not cover the existing pregnancy. However, this does not mean that a pregnant woman cannot sign up for medical aid and there are host of benefits of doing so immediately.
Why do medical schemes not cover pregnant women?
If you are at the receiving end of this restriction, you may feel that the medical schemes are being unfair. You desperately need medical aid cover and it seems like medical schemes are purposely discriminating against pregnant mothers. This is not so.
If you had medical aid cover prior to falling pregnant then you can rest assured that your childbirth costs will be covered in a private hospital, with some restrictions depending on your plan. Higher plans will allow you to give birth at just about any private hospital and even pay a higher tariff for your obstetrician.
However, if you are only applying for cover after falling pregnant then you will have to face the reality that the scheme is going to refuse the pregnancy and childbirth costs of your current pregnancy. Waiting periods are in place to protect medical scheme members.
It prevents the scheme from financial drain whereby consumers join a scheme, use benefits and then terminate their membership thereafter. This is known as anti-selective behaviour and was an ongoing problem for medical schemes for many years, not just among pregnant women.
Anti-selective behaviour hurts the loyal members of the medical scheme who have been contributing towards their cover for years and even decades without needing cover. Until a few years ago, some schemes were allowing women to qualify for cover for their pre-existing cover if they were less than 6 weeks pregnant. This did not entirely curb the abuse.
Can a pregnant woman join a medical aid?
Yes, pregnant women are allowed to join a medical scheme, whether they sign up for their own cover as the main member or as an adult dependant on a spouse or parent’s medical aid. However, the costs of the pre-existing pregnancy will not be covered. All other legitimate medical services, that are not related to pregnancy or any other pre-existing condition, will be covered provided that it does not fall within a waiting period.
Nevertheless this should not detract pregnant women from signing up for a medical aid as soon as possible. Your newborn baby is immediately covered at birth. With the possible costs of neonatal ICU running into the tens of thousands of Rands daily, medical aid cover will ensure that your baby continues to receive care within a private hospital.
Furthermore, a host of other medical events can arise in which case the medical aid will cover the pregnant mother provided that it is not pregnancy-related and there are no waiting periods applicable at the time. For example, you may have a car accident or sustain a severe fall. Without medical aid you will have to spend days or weeks in a government hospital and possibly even have your baby at this public facility.
Pregnancy and Childbirth Delivery Costs
The costs of pregnancy and childbirth using private service providers can be exorbitant. With gynaecologists facing ever rising malpractice insurance premiums, the cost of giving birth outside of a state facility are due to skyrocket. Even a three day maternity stay at a private hospital can easily cost R10,000. This excludes the cost of the gynaecologist, theatre time for a Caesarean section, anaesthesiologist and paediatrician.
Collectively an expectant mother will pay around R30,000 for a C-section delivery without complications. This does not include the prenatal costs prior to delivery, which includes gynaecologist consultation fees, ultrasounds, blood tests, supplements and any medication that may be necessary.
It is important to consider the benefits of a medical aid and weight it out against the costs. Firstly, you have to be practical about your ability to afford a medical aid. It can start from R1,100 per month for a single adult member. There is cheaper cover for low income earners and this should be discussed with the scheme directly.
Medical aid should be a long term commitment. However, the access to private healthcare does not begin and end with medical aid alone. Many people self fund their healthcare out of their own pockets or use credit facilities. If you cannot get medical aid cover for a pre-existing pregnancy, this has to be considered as an option. Private hospitals do offer special maternity packages for non-medical aid patients but this has to be paid upfront.