Congratulations on your pregnancy. Alongside the excitement, you likely have a pile of practical questions about what your medical aid will pay for. This article answers the most important ones directly.
Does My Medical Aid Have to Cover My Birth?
Yes — to a point. Normal delivery and obstetric emergencies are Prescribed Minimum Benefits (PMB). Your scheme cannot refuse to cover the birth event itself.
What PMB does not guarantee: - Funding of routine antenatal visits (these are not PMB) - Payment of specialist fees at your obstetrician's rate (shortfalls are common) - Full cover for your C-section if you chose an elective procedure at a non-DSP facility
Am I in a Waiting Period?
If you joined your medical aid scheme less than 12 months ago, you may still be in a maternity waiting period. Call your scheme's member services line and ask:
- Is there a maternity waiting period on my plan?
- How many months remain on my waiting period?
- What is covered during the waiting period?
Remember: PMB emergencies must be covered regardless of waiting period. If your pregnancy has complications — severe pre-eclampsia, haemorrhage, premature labour — your scheme must fund emergency care even if you are mid-waiting period.
What is typically NOT covered during the waiting period: routine antenatal visits, planned delivery costs, the named maternity benefit.
What Will the Birth Cost?
Start by getting this information:
From your obstetrician's rooms: - Will my obstetrician bill at medical aid tariff, or above it? By how much? - What is the estimated total fee for antenatal care + delivery?
From your medical aid: - What is my named maternity benefit (rand amount)? - What does it cover? (facility, obstetrician, anaesthesiologist, paediatrician?) - Is there a designated hospital or designated service provider (DSP) I should use?
A typical private C-section costs R40,000–R70,000 in total specialist and facility fees. Most plans offer maternity benefits of R20,000–R50,000. The gap between plan benefit and actual cost is the shortfall you carry.
Antenatal Visits: Will They Be Covered?
Probably partially — it depends on your plan: - Comprehensive plans: Often include a named antenatal benefit for 8–12 visits. - Mid-tier / savings-based plans: Antenatal visits may draw from your medical savings account (MSA) or day-to-day benefit. This can deplete your MSA early in the year. - Hospital plans: Typically do not cover out-of-hospital antenatal visits at all.
Routine antenatal care across a pregnancy (visits, scans, blood tests) can total R15,000–R30,000. Build this into your budget and check how your plan categorises these costs.
Key Scans and Tests: What to Watch For
Foetal anomaly scan (20-week scan, morphology scan): Typically R3,000–R5,000. Covered on many plans but may be charged to your day-to-day benefit.
First-trimester combined screening (nuchal translucency + bloods): R2,000–R4,000. Funding varies by plan.
Glucose tolerance test (GDM screening, ~26–28 weeks): R500–R1,500. Usually funded as a pathology test.
Group B Streptococcus (GBS) swab (35–37 weeks): R500–R1,000. Funding varies.
Ask your scheme before each investigation whether it is covered and from which benefit it will be drawn.
NICU: The Risk You Need to Plan For
If this is a high-risk pregnancy (multiples, prior premature birth, gestational diabetes, pre-eclampsia, advanced maternal age) — or even if it is not — understand your NICU benefit now. NICU is the catastrophic cost event in maternity.
NICU costs in SA private facilities: R5,000 to R50,000+ per day. A two-week admission can cost R100,000–R400,000 in facility fees alone, before neonatologist fees.
Ask your scheme: - Is there a specific NICU or neonatal benefit? What is the rand limit? - Is NICU funded from the maternity benefit, the overall hospital benefit, or separately? - What tariff rate applies — will there be shortfalls above tariff on the neonatologist's fees?
If your scheme's NICU cover is limited and you are in a high-risk pregnancy, discuss with your financial advisor whether your gap cover is adequate.
Gap Cover: What It Covers at Birth
Gap cover pays the difference between what your scheme pays (at medical aid tariff) and what your specialists charge. In a typical private birth:
- Obstetrician shortfall: R5,000–R15,000
- Anaesthesiologist shortfall: R3,000–R8,000
- Neonatologist shortfall: R2,000–R5,000
Combined shortfall on a straightforward C-section: R10,000–R28,000. Gap cover absorbs this.
The overall payment limit (OPL) on most SA gap policies is approximately R220,000/year. This is sufficient for a normal delivery. For a complex birth with a NICU admission, the OPL may be tested.
Planning Checklist: Before Your Third Trimester
| Action | Why |
|---|---|
| Confirm waiting period status | Know whether planned delivery is covered |
| Get maternity benefit rand amount from scheme | Benchmark against expected costs |
| Ask obstetrician for billing rate | Estimate shortfall in advance |
| Confirm gap cover is in place and OPL amount | Know your shortfall protection |
| Ask about NICU benefit — rand limit and source | Critical for high-risk pregnancies |
| Check whether your chosen hospital is a DSP | Non-DSP may result in co-payments |
| Register with scheme's maternity programme | Many schemes have dedicated midwife lines + early registration benefits |
Support Resources
PANDA (Post and Antenatal Depression Association): www.panda.org.za Perinatal mental health support for parents
South African Midwives Association (SAMA): www.sama.org.za
La Leche League SA: www.lalecheleague.co.za Breastfeeding support
Talk to Eldon
Get help understanding your maternity cover options →
This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).