It’s the call our Profmed consultants dread receiving. A brand new mom-to-be has just found out she’s pregnant and she’s called to ask about her medical aid options. Until this point, she hasn’t been on medical aid. This could be for any number of reasons, but generally it’s because she hasn’t really thought she’s needed it. She’s young, healthy and doesn’t have a family yet.
And that’s when our consultants deliver the bad news – pregnancy is a pre-existing condition that is excluded for 12 months after joining a medical scheme. All of the costs associated with scans, visits to the OBGYN and childbirth are not covered. It’s a painful conversation, and one that medical schemes around the country are having on an almost daily basis. If you’ve been a member of a medical aid for 12 months before falling pregnant, you’re covered. Unfortunately, many new moms who didn’t join a medical aid soon enough either didn’t expect to fall pregnant so soon, or they simply didn’t know about the exclusion. Why is pregnancy a pre-existing condition? Many expectant mothers find the exclusion unfair. Pregnancy is a gift, but the costs associated with that gift can be daunting, even if you do have full medical cover. It’s these high costs that are the reason behind the exclusion, however. The Medical Schemes Act says that medical aid schemes are entitled to impose a three month general waiting period and/or a 12-month condition-specific waiting periods for any pre-existing medical condition, such as pregnancy.
The Act makes specific provision for the imposition of waiting periods to protect the current membership pools of medical schemes from
“selective abuse.”
Selective abuse is characterised by only wanting to join a scheme once you find out that you need medical aid for something specific, such as disease or, in this case, pregnancy. This is important because the funding model of all medical schemes is based on cross-subsidisation. The idea is that younger and healthier members pay their monthly contributions for a reasonable period without needing to claim anything major. During this period, they are effectively subsidising the higher claims of older or more sickly members, as well as the expensive and unexpected expenses of both young and old members. These include unexpected operations as well as things like pregnancy.
Over time, the younger and healthier members will age or require medical assistance themselves, and they in turn benefit from the members who contribute to the risk pool but do not currently claim from it.
“Selective abuse”
of medical scheme funds happens when large claims are made shortly after joining a scheme. This means funds are drawn from the risk pool by members who have not first contributed to it. If allowed to happen unchecked, the result will be increased contributions for all members, because cross-subsidisation would no longer work. It’s for this reason that the Act has specifically mandated waiting periods. Pregnancy and childbirth are included in this list because they are expensive – and if complications arise, medical costs can skyrocket. That is the bad news. Now for the good news. Even if you become a medical aid member after you are pregnant, your little one gets the protection he or she deserves from the instant they first draw breath. If you are pregnant, join a medical aid as soon as possible Whether or not you’re planning to fall pregnant within the next 12 months, the sooner you join a medical scheme the better, even if you begin with a hospital plan. The important thing is to be covered – that way any unexpected exclusions will hopefully not pop up during your waiting period. Plus, if you are planning a family in the future, when you join a scheme before you are pregnant, you have full access to all the maternity benefits the scheme has to offer. However, if you have fallen pregnant and you are not currently a medical aid member, you should still join as soon as possible. The main reason to join a medical aid scheme is to ensure your baby gets the best possible healthcare from the get-go. You also don’t want to require non-pregnancy related medical attention without medical cover in place. Profmed Maternity Benefits All of Profmed’s options provide maternity benefits in- and out-of-hospital, except the ProSelect option, which only covers the delivery and pregnancy-related hospitalisation. All Profmed babies are covered by the Scheme and must be registered within the first month after birth. Just download the Profmed App to register your baby.
The ProSecure and ProActive Plus options offer additional benefits paid from Scheme risk, which include ultra-sound scans, doctor or midwife consultations. The ProSecure option offers a NIPT Test, a lactation and nutrition consultation.
All moms have access to the Tums2Tots Baby and Toddler programme. Registering on the Profmed App to gain access. The programme provides a six-week post-natal home visit for baby’s vaccinations, gifts for mum, an exciting toddler programme and other useful and exciting benefits and services.
Source: Profmed
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