Is your family fully covered for medical expenses related to pregnancy and childbirth? If you do not have gap cover in place, there are certain maternity/childbirth expenses that will not be covered by your medical aid or hospital plan. We unpack the additional expenses you can expect in this case, and how gap cover can assist you financially.

What is gap cover?

Should there be a gap between the rate paid by your medical scheme and actual medical bills due to higher rates for certain doctors and specialists, you will be responsible to cover these costs. Gap cover is designed to pay for this shortfall between medical aid payments and your actual medical costs, to avoid that you have to spend your savings on these expenses.

Full cover vs 100% cover

Many individuals are under the impression that their medical scheme will cover all medical expenses since they stipulate 100% cover. This, however, refers to paying 100% of the scheme tariff, which is a predetermined rate by each medical scheme for specific treatments and procedures.

For example, if your gynaecologist charges R900 for an antenatal consultation and the scheme’s tariff is R500, they will only pay R500 if they cover 100%. Therefore, you are responsible for paying the rest. If you have full cover on the other hand, the scheme will pay the R900 in total.

Specialists such as gynaecologists and paediatricians generally charge a 400% tariff on average. Individuals who do not have gap cover can expect to pay between R30 000 and R40 000 additionally for pregnancy and childbirth medical expenses. Therefore, it is important to consider a gap cover policy before starting a family.

Maternity and childbirth medical expenses

There are a number of additional medical costs that individuals are often not aware of before falling pregnant. It is therefore significant that the following factors are taken into account upfront:

Gynaecologist deposit: some gynaecologists require a deposit before childbirth. Unfortunately, not all gynaecologists follow the correct procedure in which the deposit does not appear on the statement of the medical scheme. This is referred to as ‘split billing’, meaning that your gap cover will not cover this expense as a tariff increase.

Lodging fees: your lodging fees are not necessarily covered if your baby needs to stay in hospital longer and you choose to stay on as well.

Elective caesareans: it is important to check whether your medical aid plan covers caesarean section deliveries, if medically unnecessary.

Maternity programmes: register with your scheme’s maternity programme to access maternity benefits, since you might only have access to these benefits when registered.

Newborn registration on gap cover: you have to register you baby on your gap cover policy within 6 months of birth. If you fail to do so, any claims related to your baby since he/she was born will be rejected and waiting periods will apply when registering your baby after 6 months.

Waiting period: if considering taking out gap cover, this should be done well in advance of conceiving, since there is usually a 10- to 12-month waiting period during which pre-existing conditions (including pregnancy) are excluded.

By having a gap cover policy, you are protected from having to access your savings to fund these expenses. Gap cover can also provide peace of mind in knowing that additional costs you may not be aware of, will be taken care of – especially when maternity leave and a reduced (or no) income plays a major role financially.