Maternity Benefits for Pregnancy and Childbirth

South African medical schemes provide comprehensive benefits for pregnancy and childbirth, whether you opt for public or private healthcare services. Fortunately the South African public healthcare system is free for citizens but many prefer private practitioners and facilities instead. For most South Africans, medical aid is often the only way to afford these private healthcare services.

Unlike private health insurance in other countries, South African medical aids pay for the pregnancy and childbirth related costs. However, it depends on your plan. Full/comprehensive medical aid with out-of-hospital benefits will pay for mother’s and baby’s needs both in and out of hospital.

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A hospital medical aid plan will only cover in-hospital bills for both mother and baby. The extent of cover and limits are outlined under the maternity benefits of your scheme’s guidelines for your specific plan, and varies among schemes and different plans.

Private hospitals will admit expectant mothers without medical aid cover but this usually requires upfront payment. The costs can vary but a childbirth package from a South African hospital can vary from R15,000 to R30,000, depending on the facility and type of birth. This is excluding the obstetrician’s fees.

Out Of Hospital Pregnancy Benefits

Pregnancy lasts for approximately 40 weeks in humans and during this time you will need extensive medical care. From monthly ante-natal check ups with your gynaecologist, to scans, blood tests and sometimes medication or supplements, pregnancy can be a very costly experience in your life. Understanding what your medical aid will cover and where you are liable for bills will assist you in financially planning your pregnancy.

Your out-of-hospital benefits are only applicable if you have a full/comprehensive medical aid plan with day-to-day benefits. Mothers who have a hospital only medical aid plan will not have cover for these services/products and will instead have to bear the cost out of their own pocket or use a public healthcare facility.

The levels of cover for your out-of-hospital pregnancy bills depends on your level of cover and individual limits. Some plans have a total out-of-hospital benefit for all day-to-day bills or a savings account, while others have specific limits for different providers. The limit for each service/product can vary significantly.

However, many women find that their gynaecologist-obstetrician does not charge medical aid rates and is contracted out of medical aid. This means you as the patient have to settle the bill directly with the doctor. Thereafter you can claim back the amount from the medical scheme, to the maximum of the medical aid rate’s cover for that consultation/procedure. Any shortfall comes out of your own pocket.

In Hospital Childbirth Benefits

These benefits are available irrespective of whether you have a full/comprehensive medical aid plan or only a hospital plan medical aid. It covers you from the time of admission for childbirth up until mother and baby are discharged. It includes the doctors’ fees (gynaecologist/obstetrician, paediatrician for baby, anaethetist), operating theatre time if it is a caesarean section, hospital stay for mother and baby and medication administered in the hospital.

The rates for these different products/services within hospital is paid according to the medical aid rate (NHRPL ~ National Health Reference Price List). Most private hospitals in South Africa charge these rates and usually nothing more. However, if you want a private room in the maternity ward, opt to stay longer because baby is not being discharged immediately or any other product/service out of the usual benefits then you will have to pay the difference directly to the hospital.

Once again, many private doctors and medical specialists charge higher than medical aid rates. Therefore you will be held liable for any shortfall in medical aid payments. Some practitioners require that you pay these fees upfront prior to giving birth, while others will bill you shortly after you leave hospital. You will have to settle the practitioner and then claim back from your medical aid who will reimburse you, provided that it is not above the medical aid rate for that specific service/product.

It is common for shortfalls to occur between what the medical aid pays and what the doctor demands. These shortfalls will come out of your pocket as the patient/medical aid member unless you have medical gap cover for such instances.