No way to treat a woman: Ask Georgie
Sorry, you’ve got limited cover for this ‘women’s issue’, a financial services provider tells a doctor after trying to claim for her non-elective Caesarean
WHEN Dr Julianne Grundy needed a non-elective Caesarean in October last year, she didn’t expect to return to work soon afterwards.
Caesareans are, after all, classified as major surgery.
She spent four nights in hospital and was booked off for six weeks by her obstetrician in order to recover at home with her newborn.
Grundy was placed on heavy pain medication and couldn’t drive for six weeks. She had no reason to be concerned because she had professional insurance in place through the financial services company Professional Provident Society (PPS).
The company offers tailor-made insurance, investment and healthcare products for graduate professionals with a qualifying four-year degree.
Grundy was shocked to find though, at claims stage, that PPS only paid her out for her four days in hospital.
“I was not allowed to drive for six weeks: I work an hour from home and was also placed on heavy pain medication for the first 10 to 14 days, so it wouldn’t be considered safe to work on patients with the amount of medication I was on,” Grundy told me.
“I want an explanation from PPS as to why they do not recognise a C-section as reason enough to pay out, but something as ridiculous as bunion on your toe is.
“If a man chooses to get into a car, drive drunk and breaks his arm, PPS is prepared to pay him fully for his time off.
“But as a female who has given birth to a baby and had no choice but to get the Caesarian done, PPS says no, we don’t recognise that as reason enough. “It’s sexism at its finest.” Grundy has since discovered that other professional insurances do pay out – in full – for the C-section period.
“So why do they recognise it as reason enough to pay out, but PPS doesn’t?
“Clearly, because I should be paid out and they are not as out-dated as PPS is, or maybe it’s because they have females on the board who have actually experienced what the procedure entails so understand there is no way to return to work three days later.”
For the record, PPS has three women on its board of 14, which is an improvement on the four women on a board of 19 of the major healthcare insurer she was referring to. Still, women’s representation on these boards remains woefully inadequate.
The PPS policy on pregnancy does seem sexist and drafted by people who haven’t experienced the trauma of a C-section.
As Grundy points out, “any of them who would have undergone such a surgery would clearly have seen it is impossible to return to work three days later and function properly”.
Grundy, who took out PPS cover in 2012, says it’s the first time she’s attempted to claim for sickness cover and this is her “reward”. And with more women as part of the professional workforce than ever, she’s accusing PPS of refusing to change with the times.
Her matter was taken to PPS’s internal arbitrator, who noted C-sections are not a listed condition in the PPS Provider Policy, but that an endorsement to the contract covered hospitalisation.
The arbitrator wrote: “The general implication of your letter seems to be that PPS is discrimination against women (sic)… The conditions listed in Appendix E are all defined in very clear and express terms. This leaves no room for interpretation.
“A scrutiny of Appendix E clearly shows that caesarian sections do not fall within the scope of any of the conditions listed in the appendix and that it, consequently, does not qualify for a valid claim.”
He then refers to an extract in the policy contract: “Where a sickness is directly or indirectly attributable to pregnancy, confinement or miscarriage, but the specific sickness contracted by a policyholder to whom the seven-day waiting period applies (refer to the latest policy certificate issued by PPS Insurance) is not one of the conditions listed in Appendix E and/or the sickness does not meet all of the claim criteria and benefit requirements listed in Appendix E, the payment of a Sick Pay Benefit will be limited to the period that the policyholder was hospitalised, provided that this hospitalisation period was at least a period of four consecutive days.
“If one bears in mind that, first, the gradual extension of cover for pregnancy related conditions under this particular policy was implemented over the years without any premium increase and, second, that male policyholders, who obviously do not enjoy cover for pregnancy related conditions, pay exactly the same premiums under this policy, it follows that women can hardly claim to be the victims of discrimination under this particular policy.”
This is a moot point: men are viewed as “high risk” and as Grundy suggested, PPS would be likely to pay them out if they were injured in a crash as result of their own reckless behaviour.
Plus, professional women are not likely to have more than two children.
I contacted PPS about the issue and was told: “PPS is in no way unsympathetic towards the member’s concerns but is required to adhere to the agreement that was entered into between PPS and the member.”
They then cited the terms of the PPS Provider policy and said the arbitrator stands by the original decision.
“It is important to state that in November 2012, 17 additional conditions related to pregnancy were added to the policy. However, the condition that the complainant experienced, a caesarean section, fell beyond the ambit of these conditions, as was stated in Appendix E of her policy. Instead, the ‘hospitalisation criteria’ was used to honour the claim which was paid out, thus fulfilling the insurance contract.”
I’m with Grundy on this. Non-elective Caesareans are often life-saving, painful procedures that take much longer to heal than natural birth.
Rather than being “too posh to push”, women who require them medically are forced to do so by complications during labour, twin pregnancy, high blood pressure, breech births, problems with the placenta or umbilical cord, or in Grundy’s case – large birth size.
It’s a poor reflection on PPS and won’t sit well with professional women of child-bearing age.
My suggestion is before you take out such insurance – or any other – read the terms and conditions and make sure that you understand the implications.
Financial advisors selling these products should also point out to such clients that they won’t be covered once they leave hospital, should they require a C-section.
I’ve suggested Grundy takes the matter to the Financial Advisory and Intermediary Services Ombud, at 012 762 5000 / 012 470 9080; e-mail info@faisombud.co.za or by visiting www.faisombud.co.za