It is often disappointing for South Africans, particularly women, to discover that hospital plans do not cover fertility treatments. This applies to both of the different types of hospital plans – a medical aid or cash back plan. The reasons may differ but the bottom line is that a hospital plan does not include cover for what is deemed non-essential, similar to cosmetic surgery. Many people wanting to conceive view fertility treatments as essential medical procedures but hospital plans are there to cover its members for medical costs accrued due to illness, especially since it can result in death in some instances. Seeking fertility treatments to fall pregnant is your right but in South Africa unfortunately, it is only an option those who can afford it and not for every medical aid member.
Medical Aids for Fertility Treatment
It is actually not true that no medical aid in South Africa will cover fertility treatments. A few restricted schemes, like the Chartered Accountants Medical Aid Fund (CAMAF), provide a small but significant benefit for fertility treatments. However, this medical aid is only opened for membership to employees of the financial accounting and auditing industry. The majority of South African medical aids, and all open schemes, do not cover fertility treatment. The greater difficulty for South Africans is that fertility treatments are extremely expensive. So much so that most people cannot afford it unless they take out an additional home loan. Fortunately these days there is specialised credit for these treatments in the form of a medical loan – for those who can qualify for it. Fertility treatments are not covered by government hospitals either, unless a medical school is conducting a clinical trial on a new treatment, which is uncommon.
Hospital Cash Back for Fertility Treatment
Many consumer believe that hospital cash back plans are the saving grace where medical aids fall short. However, it is important to understand how these policies work. Hospital cash back plans are exactly what the name says, it is a cash benefit for when you fall ill or are involved in an accident and hospitalised. Non-essential services like cosmetic surgery and fertility are not covered. In addition a hospital cash back plan has a 2 to 3 day deferred period which means that the beneficiary cannot lodge a claim for being hospitalised for less than 2 to 3 days. Most fertility treatments that do require hospitalisation almost never need a person to be in hospital for longer than 2 days unless complications arise. Even so, premium hospital cash back plans pay only R5,000 per day in hospitalisation. Fertility treatments can cost as much as R150,000.
Causes of Infertility Covered by Hospital Plans
Infertility is a consequence of some underlying defect or disease. In women, it may be an anatomical defect of the ovaries, fallopian tube or uterus or it may be due to diseases affecting these organs. Unless these diseases or defects are corrected, a woman may be unable to conceive a child. Two of the common conditions that contribute to infertility and often require surgery are polycystic ovarian syndrome and endometriosis. In polycystic ovarian syndrome there is an overproduction of male hormones, with the formation of cysts in the ovaries, anovulation and insulin resistance. With endometriosis, the inner lining of the uterus (endometrium) grows at other sites usually around the female reproductive organs. Both these conditions need to be treated medically, and at times surgically, and are covered by medical aids.
However, you need to bear in mind that medical aid hospital plans do not cover out-of-hospital treatments including the medication for these conditions. Only surgery will be covered once you are admitted into hospital as part of the hospital cover on your medical aid. If you are in hospital for more than 2 to 3 days and have had treatment in an approved hospital then you may also receive a payout from a hospital cash back plan but this is dependent on your policy. It is possible that a woman can fall pregnant once these diseases are properly treated. It is only once treatment does not allow a person to conceive that fertility treatments should be considered. This may involve the use of fertility drugs like clomiphene citrate (trade name Clomid) or procedures such as in vitro fertilization (IVF) or intracytoplasmic sperm inject (ICSI). Both are not covered by hospital plans in South Africa.