Can you join a medical aid if you have just fallen pregnant?
Importance of medical scheme membership and cover
Most moms-to-be will agree on the importance of discussing with their partners some of the “big parenting issues” such as tossing their birth control, childcare, working vs staying at home and financial planning, to name but a few. And then there are other factors to be considered, such as giving up binge drinking, smoking, monitoring your caffeine intake and aiming for a healthy lifestyle.
Motherhood and pregnancy are two universal experiences that are incredibly unique to every woman. One aspect that is however of vital importance that is often overlooked, especially for first-time moms, is the importance of belonging to a medical aid scheme at the time of falling pregnant.
Currently, the average cost of a normal delivery in a private hospital in South Africa is in the region of R40 000. Should you not be able to give normal birth, or opt for a caesarian section, you could be looking at a hospital bill of about R60 000.
Costs may also increase drastically if there are complications with the pregnancy or the birth. In South Africa about 15% (or one in seven) babies are preterm; so if your prem baby needs to be hospitalised for respiratory distress, s/he may need to spend a few days, a few weeks, or even a few months, in hospital. The length of hospitalisation will depend on her/his gestational age (measured in weeks), how developed s/he is and whether s/he has any health complications. Your total hospital bill in this regard can vary between a few tens of thousands to a few million Rand.
The big shock
Medical schemes receive calls from moms-to-be on a daily basis who have just found out that they are pregnant. They want to immediately join a medical scheme, as of course, they want the peace of mind that their medical scheme will pay for the birth of their new baby, with the assistance of their trusted gynae and paediatrician, in a private hospital.
Unfortunately, medical schemes in South Africa will not foot the bill if you are already pregnant when joining them as a new member. For many, the thought of having to give birth in a state hospital may become a dreaded reality if they do not have sufficient funds/savings to foot the hospital and medical bills themselves.
Why will medical schemes not cover your birth?
Medical aid schemes in South Africa are entitled to impose certain waiting periods on new members and/or their dependants when joining a medical scheme. Generally speaking, waiting periods will depend on the amount of time an applicant has been (or has not been) a member of a medical scheme in South African at the time of joining a new scheme.
The Medical Schemes Act (“Act”) makes provision for medical aid schemes to impose a three (3) months general waiting period and/or a twelve (12) months condition-specific waiting period(s) for any pre-existing medical condition(s), such as pregnancy. The Act makes provision for the imposition of waiting periods to protect the current medical scheme membership pool from “selective abuse”. This term is generally used to refer to people wanting to only to join a scheme once they need to incur medical expenses (for example giving birth). In this regard, the Act offers some form of protection to medical schemes from people that only join when they require hospitalisation and/or expensive medical treatment.
The funding model of medical schemes is based on the model of cross-subsidisation. Generally speaking, younger / healthier members contribute to the funds of a scheme for a reasonable period whilst not claiming anything major. During this period they subsidise the higher claims of older / more sickly members, or the other big-ticked and unexpected expenses of young and old. Over a period of time though, the younger / healthier members will get older and will in turn benefit from younger and healthier members who contribute to the risk pool.
“Selective abuse” of medical scheme funds, where large claims are made shortly after joining a scheme and then cancelling membership, will result in increased contributions for all members.
Waiting periods
Waiting periods are not always imposed when joining a medical scheme. It is done always at the scheme’s discretion. The Act makes provision for two kinds of waiting periods:
- A general waiting period – during this period, members have to pay their normal monthly contributions, but are not entitled to claim any benefits whatsoever, except in certain instances with claims relating to Prescribed Minimum Benefits (PMBs).
- A condition-specific waiting period of up to 12 months – during this period, members have to pay their normal monthly contributions, but any pre-existing health condition(s) will be excluded. All medical costs associated with the condition(s) during the first 12 months will be for the member’s own pocket.
The table below provides a summary of the provisions applicable to waiting periods as per the Medical Schemes Act:
| Category | 3 months general waiting period |
12 months condition specific waiting period |
|---|---|---|
New applicants who:
|
Yes | – |
| New applicants who are members of a registered medical scheme in SA for less than 2 years | – | Yes |
| New applicants, or applicants who are not members of a registered medical scheme in SA for at least 90 days prior to the date of application | Yes | Yes |
Therefore, if you have not belonged to a medial scheme for 90 days or longer prior to applying for membership once you find out that you are pregnant, a medical scheme in South Africa may impose a 3 months general waiting period, as well as a 12 months waiting period on the pregnancy, confinement and related conditions.
Real peace of mind
Pregnancy and giving birth can be one of the most amazing experiences you may ever live to experience, however, it can also be one of the most expensive ones. Before you start thinking of baby names, make sure that you are a member of a medical aid scheme in South Africa.
Image: Freepik
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