There are number of different health-related financial products with medical aid leading the way in covering healthcare costs. Pregnant women who want to access private healthcare services will either need to have medical aid or the financial resources to cover these costs. In recent years, other forms of health cover have emerged with maternity benefits but all of these financial products differ and may have limitations when it comes to pregnancy-related costs.
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Firstly, it is important to understand what a hospital plan means in South Africa. It could refer to a medical aid with hospital benefits only (in contract to full or comprehensive medical aid cover) or it could refer to hospital insurance products. These are two very different financial products and should not be confused with one another. Hospital insurance cannot replace medical aid and vice versa.
A simple way to understand the difference is that medical aid is administered by medical schemes and pays for medical expenses. This payment may be made directly to the service provider (hospital or doctor) or sometimes to the medical aid member who has to then settle the relevant service provider. Any shortfalls will have to be paid for by the member or through medical gap cover if the member has this type of cover.
A hospital insurance plan, also known as a hospital cash plan, pays the policyholder directly. The payout depends on the level of cover purchased and the duration of the hospital stay. It is also subject to a single claim limit as well as an annual cover limit. A hospital insurance policy does not pay the service provider directly and the payout may not be in line with medical expenses. It is intended to provide financial assistance to policyholders who are hospitalised, and this payout can be used for personal expenses or to settle medical bills if the policyholder so chooses.
Medical aid and hospital insurance are two entirely different products. However, both products may offer some degree of financial reprieve when it comes to hospital-related costs specifically. Medical aid is not affordable for a large portion of the South African population. Without medical aid, the majority of South African healthcare consumers cannot afford to access private healthcare services. Therefore, less expensive products that focus on hospitalisation in private facilities have grown in popularity in recent years.
Do Hospital Plans Have Maternity Benefits?
Medical aid does have maternity benefits but it is not a blanket cover for the entire pregnancy-related costs. A hospital plan medical aid will only cover childbirth costs in a private hospital. This may not always apply to all private hospitals as some plans offered by different schemes will only pay for services within a network hospital. There may also be further limitations on what may or may not be covered.
In-Hospital and Out-of-Hospital Pregnancy Benefits
A comprehensive medical aid plan will cover both out-of-hospital and in-hospital maternity expenses. Out-of hospital expenses may include gynaecologist visits, ultrasound scans, blood tests and medication or supplements. In-hospital costs for pregnancy usually refer to childbirth/delivery, the maternity stay in hospital as well as the newborn’s hospital stay as well as medical expenses for baby immediately after birth.
A hospital plan medical aid on the other hand is limiting to only covering the in-hospital costs. This applies to both the mother and baby. Hospital insurance does offer a maternity benefit where mothers receive a cash payout for hospitalisation related to childbirth but this may be restricted by the duration of the stay. Usually there is no additional cover for a newborn baby. Furthermore the payout may not be sufficient for the costs of giving birth in a private hospital.
Hospital Plans for Already Pregnant Women
Many women search for hospital cover after falling pregnant in the hope that this will cover childbirth costs in a private health facility. It is at times incorrectly thought that a basic hospital plan will cover pre-existing pregnancy. However, there is no medical aid that will cover pregnant mothers who are already pregnant at the time of signing up for cover. The same applies to hospital insurance products.
This does not mean that a pregnant women cannot sign up for medical aid or hospital insurance cover. It simply means that the pre-existing pregnancy and childbirth costs will not be covered by the medical scheme or health insurer. It is nevertheless advisable to sign up for cover immediately as medical aid in particular will still cover the newborn baby’s medical bills following birth. Furthermore other medical events may arise which are not pregnancy-related and may therefore be covered if waiting periods have passed.
Shortfalls in Pregnancy Medical Bills
A growing problem in recent years is that medical aid payouts do not cover the full medical bills. This is largely due to the fact that many private doctors and medical specialists now charge above the medical aid tariff for specific procedures. Some medical aid plans will cover up to 300% of the tariff but only for in-hospital procedures. However, with this type of plan or medical gap cover, consumers are forced to pay the difference out of their own pockets.
Hospital insurance pays out independent of the medical bills accrued while in hospital. Ideally hospital insurance is financial protection for personal expenses and loss of income while in hospital. However, this payout can be used as the policyholder sees fit. With the rising cost of medical care, a hospital insurance payout can be used to cover some of these medical bills although a hospital insurance plan is not a medical aid and cannot replace medical aid cover.