Medical aid: a necessary evil

Living with a disability is difficult enough for people with disabilities and their families. Making the situation tougher is having to deal with an uncooperative medical aid. ANLERIE DE WET does some research

oeye Swart has been fighting with medical aids for many years. Her 24-year-old son, Anton-Pierre Swart, was born with cerebral palsy. He is a dependant on Swart’s medical aid; he is unable to afford his half of the total scheme, which costs R6 000.

He has a job as an occupational health and safety officer in Port Elizabeth, but his condition allows him to work only part-time. “Although his income is too low to afford medical aid, he is still lucky enough to have parents who can take care of him – but I know there are others who aren’t as lucky,” says Swart.

Swart says that their medical aid has been refusing for years to pay for Attention-deficit/hyperactivity disorder (ADHD) and the spasms that her son experiences as a result of his condition.

“My son wants to work, but for that he needs the medication to help him concentrate and drive safely – which costs us about R2 000 per month extra on top of the medical aid fees,” she says.

“We have to constantly fight for something that’s supposed to be a given.”

Rodwill Beneckhe had and is still having the “worst experience” with his medical aid for his son.

“The amount given for equipment annually is a laughable R8 000. They even tried to send him to a rehab that was so far away that we would not have been able to see him. It wasn’t until we opened a case with the ombudsman that they suddenly gave permission for the closer rehab,” says Beneckhe.

He adds that his medical aid provider told him to make a co-payment for his son’s medication even though it is medication that should be covered by the medical aid, according to its PMBs.

Swart says: “I admit, I have diabetes and it is covered in full under the PMBs. But my son is in a wheelchair through no fault of his own and his medication is not covered.”

Simon Haifer of Medop says he ask medical aids and practitioners why the benefits for disabled products are low compared with other benefits. “I have never received a comprehensive answer. Medical aids will gladly pay for in-hospital scans that doctors request at the drop of a hat,” he says. “However, they won’t cover a decent spec product, such as a wheelchair, which could result in an early discharge; prevent the onset of pressure ulcers/sores; reduce the physical stress on the immediate family member or caretaker; and encourage greater independence.”

He says that earlier discharge would reduce long-term costs to the schemes directly, thus indirectly increasing their long-term profits.

“Some schemes have large external appliance benefits, although, in today’s market, most of the high-end products are not covered due to increasing manufacturing costs and currency fluctuations,” he adds.

Dr Elsabé Conradie, GM of stakeholder relations at the South African Council of Medical Schemes, says the PMB regulations are currently under review. “At this stage it is not possible to provide information on specific conditions and changes as the review process is still in the early phases,” says Conradie.

However, as the PMB regulations currently stand, they include the following spinal cord and non-progressive neurological conditions:

Conradie says: “In cases where the treatment includes medical management, the medical schemes must fund chronic medicine. The only limitation will be that in order for the medicine to qualify for PMB level of care, the specific pain medicine must be available in the public sector. The medical schemes may have a medicine formulary as well and fund only the drugs on the formulary in full.”

She adds: “Regulation 15I(c) determines if the formulary drugs were used, but if they are not effective or will cause adverse reactions or have already caused adverse reactions, the medical scheme must fund any drug as prescribed.”

Many medical aids have a payback system where patients have to pay out of pocket for medicine and treatment and then the medical aid will pay back the money if the medicine or treatment is accepted within the patient’s benefits. Swart says this is a problem for people with low incomes (which is often the case for people with disabilities), who spend a lot of money on private medical aid and do not have the cash-in-hand to pay for the treatment when it is needed.

Conradie says the payback system is allowed under the Medical Schemes Act, 131 of 1998, which states that members are responsible to claim from the medical scheme and not the provider. “This statement was legally challenged and the final court ruling indicated that in cases where the provider has a specific contract with the medical scheme, direct payment must be made to the provider. In other cases the member may be asked to pay the doctor and then claim back from the scheme,” explains Conradie.

Haifer says: “People should definitely speak to their therapists regarding internal procedures in the medical scheme, which may allow for increased benefits, such as PMB, ex-gratia payments (paying for treatment without being legally obliged), and trauma benefits.”

Another option is to politely express one’s opinion in writing to the medical aid regarding
the effect of the extremely low benefits on its patients. “This may be the only way to get the schemes to hear people’s calls for help,” concludes Haifer.

We at Rolling Inspiration urge people with disabilities and their families or caretakers to study and understand their healthcare benefits and legal rights.

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