One of the first questions that comes up when finding out that you are pregnant, is the medical cost involved with pregnancy and childbirth.
A delivery in a private hospital does not come cheap, and a state-hospital delivery may not be your thing, although you might not have a choice.
Here are some questions and answers on pregnancy and medical schemes:
Can I join a scheme when I am already pregnant?
Yes, you can, but no scheme will pay for that particular pregnancy or for the birth of the child. However, you will be covered for other medical expenses, such as if you were in a car accident, or needed to have your appendix removed.
Why can’t I get cover for this pregnancy?
This is to protect the interests of other members, as, in the past, it often happened that women joined the scheme on learning that they were pregnant, had the baby, and then resigned as a scheme member. That meant they claimed a lot more than they paid in, which had a negative effect on other members.
So if I join a scheme, when can I claim for pregnancy and childbirth?
If you fall pregnant after joining the scheme, you will be covered. You could, however, be subject to a three-month general waiting period on joining.
How does the waiting period work?
If you have been a member of any SA scheme for more than two years (and there has not been more than 90 days’ interruption in your membership), you will not be subject to the three-month waiting period.
What if I am joining for the first time?
You could be subject to an exclusion period of 12 months for conditions that you have had before you joined, such as a back problem, or being pregnant. That is the maximum amount of time for which you may be excluded from treatment for certain conditions.
Sometimes, if you are forced to join a scheme as a condition of employment, the scheme can choose to waive waiting periods – but they don’t have to.
When it comes to pregnancy, what is the difference between a hospital plan and a full medical scheme?
A hospital plan will mostly only pay for things that happen in a hospital after you have been admitted as a patient. So, if you are pregnant, things such as scans, prenatal testing and antenatal classes will be for your own pocket, but a delivery in hospital will be covered.
On some options, it also depends on how much money you have in your Savings Account, or whether there is a separate benefit for pregnancy.
Will my scheme pay for a midwife and a home birth?
This depends on your scheme and on the option you have chosen. Do check beforehand by giving your scheme a call, just to make sure.
Do I have to use a specific hospital or doctor for the birth of my baby?
It depends on your scheme and the option you have chosen. If your scheme has a network of doctors and hospitals, you might have to make co-payments from your own pocket if you choose to use another hospital, or a doctor who is not part of the network.
Does my scheme have to pay for a Caesarean?
No, not unless it is medically justifiable. If you choose to have a Caesar anyway, your scheme might expect you to pay the difference in cost between that and a natural birth.
What if there are complications during the birth?
If you have hospital cover, and you are in a network hospital, the costs of complications will be covered.
When can my baby become a member of the scheme?
The minute it is born – but you will have to register it as a dependant beforehand.
If my scheme says it covers 100% of medical fund rate for the birth of my baby in hospital, what does that mean?
The medical fund rate could be lower than what your hospital charges – especially if it is an out-of-network hospital. If you don’t use the network hospital or network doctors, you could have to pay in quite a bit, depending on your scheme option. Consider getting gap cover.
Is a delivery in a state hospital free?
It can be very little, if, for instance, you can prove that you are unemployed, or have no income. But if you are working, you could be charged a small fee, depending on your income.