Medical Schemes That Cover Fertility Treatment

This year is an important one for the many couples – as many as one in six – who require treatment for the medical conditions that cause infertility. Up to now, the vast majority of South African couples had to fund their fertility treatment privately, as fertility treatments were generally excluded by medical aids. However, from the beginning of 2021, Discovery Medical Scheme – South Africa’s biggest medical scheme – will be offering cover for fertility treatments, although subject to rigorous terms and conditions and only for a limited number of its clients.

At Cape Fertility Clinic we are very pleased that Discovery Health will now be covering fertility treatment subject to certain terms and conditions.

Making quality fertility treatment affordable is one of our team’s most cherished values and we have diligently participated in creating awareness and pressure on the medical aid industry to provide cover for fertility treatments, as a member of the Southern African Society of Reproductive Medicine and Gynaecological Endoscopy (SASREG) and working with other organisations.

Cape Fertility is proud to be a SASREG-accredited fertility clinic and we are also very proud that one of our fertility specialists, Dr Sulaiman Heylen is the President of SASREG.

This society serves to protect the interests of patients undergoing fertility treatment and represents specialists – ranging from gynaecologists, embryologists and scientists to fertility and theatre nursing sisters, allied practitioners, psychologists and social workers in the field of Gynaecological Endoscopy and reproductive medicine.

For many years, fertility treatments were not covered by medical aids in South Africa, this despite the fact that infertility is a listed prescribed minimum benefit disease.

The fact that infertility is a prescribed minimum benefit disease should mean that you are covered for infertility treatment, irrespective of the medical aid plan that you are on.

However, as Saskia Williams, founding member and CEO the Infertility Awareness Association of South Africa (IFAASA) explains, the reality is that the treatment of infertility is excluded – the only prescribed minimum benefit disease on the exclusion list of most medical aids. Although open medical aids will pay for diagnosis, once you have been diagnosed with infertility, the treatment of the disease will not be covered.

In a recent interview along with Williams on eNCA, Dr Heylen elaborated on the injustice of the fact that cover for fertility treatments is excluded from medical cover in South Africa.

Firstly, infertility is caused by medical conditions that affects both women and men, with only a very few unexplained cases of infertility. In fact, in around 40% of cases, infertility is due to a female factor, while in 40% of cases it is a male factor, with the remaining 20% of cases are due to a combination of male and female factors.

Infertility is also categorized by the World Health Organization as a “Disease of the Reproductive System” and therefore treatment should be covered by South Africa’s medical aid schemes.

This is certainly how the South African law views infertility, defining this disease as one of the 270 Prescribed Minimum Benefit Diseases (PMBs) listed in the Medical Schemes Act, No. 131 of 1998. Despite this, medical schemes have simply excluded fertility treatment from their cover.

This is not the case in other countries, where fertility treatments are commonly covered by medical schemes – making South Africa a notable exception. Dr Heylen says that it is important that we continue to work towards ensuring South African men and women have the same rights as other couples across the world when it comes to medical cover for fertility treatments, especially given the fact that as many as 1 in 6 couples face infertility challenges.

These couples already face a very challenging journey to parenthood as they struggle to conceive, facing traumatic emotional challenges, the physical aspects of infertility testing and treatment, and the mental strain that affects every aspect of life – work, family and friends. The fact that medical schemes exclude cover for infertility – a medical condition requiring medical treatment despite the fact that it is legally a prescribed minimum benefit disease – is not only grossly unfair discrimination, it also adds to the unwarranted stigma and the shame around infertility, and places a significant financial burden on these couples.

Discovery Health’s move to offer limited cover for fertility treatments to a small minority of its clients is a significant step in the right direction, the result of many years of work and effort.

Williams notes that since 2014, IFAASA along with SASREG, attended countless meetings and presentations to pressure medical aids to pay for infertility treatment. A host of analytical findings, countless reports, public campaigns and related pressures via social media were actioned from 2015 onwards. IFAASA fertility videos posted on social media proved a hit when going viral last year as the public applied pressure to their medical aids wanting an explanation as to why it was the only disease on the list that is excluded when it comes to the payment for treatment.

“Credit must go to the public because it wasn’t long until I received a call from Discovery wanting to meet. In partnership with Dr Sulaiman Heylen, President of SASREG as well as Vice President of SASREG Dr Jack Biko, we had countless calls and zoom meetings with Discovery throughout lockdown before Discovery announced the exact details regarding the cover of the treatment of infertility. I am delighted with our ‘win’ in this regard and must thank all those who contributed including Meggan Zunckel, Dr Heylen and Dr Biko,” says Williams.

This is a significant breakthrough as, according to the Council for Medical Schemes (CMS) 2019/20 annual report, Discovery Health is the largest scheme in South Africa by some margin with 1.342 million members (33% of the total) and 2.795 million beneficiaries (31% of the total). Discovery Health Medical Scheme is an independent non-profit entity governed by the Medical Schemes Act, regulated by the Council for Medical Schemes and administered by a separate company, Discovery Health (Pty) Ltd, an authorised financial services provider.

Cover for certain fertility treatments is now available for those Discovery Health clients who have been on the two top medical plans, the Discovery Comprehensive and Discovery Executive plans, for two years or more.

The medical scheme will cover up to two cycles of Assisted Reproductive Therapy (ART) including In-Vitro Fertilisation (IVF), Intra-Uterine Insemination (IUI), Embryo Transfer (FET) and Intra-Cytoplasmic Sperm Injection (ICSI). All treatments will have to be done at a SASREG Centre of Excellence. Co-payments and further terms and conditions apply, for example, the cover is only available to women between the ages of 25 and 42, and only women under the age of 40 will typically be covered for two cycles per year, while women between the ages of 40 and 42 will be covered for only one cycle per year.

While this is a positive step forward, IFAASA and SASREG will continue to lobby for cover for fertility treatments to be made available on other Discovery Health plans and also by other medical aids in South Africa.

If you require fertility treatment or if you want to know more about the costs, cover and finance available for fertility treatment, the first step is simply to contact us by clicking here

At Cape Fertility, we value each individual patient, and we look forward to providing you with affordable quality fertility treatment, our signature individualised and personalised care, and higher success rates at our purpose-built premises in the beautiful city of Cape Town.