Medical aid dispute a matter of principle

Despite spending four months disputing a claim with her medical aid, Mandy Latimore is not giving up out of principle

Medical aids are notoriously known to be difficult to deal with when it comes to claims. Of course, there are exceptions, but, for the most part, it is extremely frustrating. Many of us might opt to scrap the refund (if we can afford to), but for others it is a matter of principle. This is exactly what motivated Mandy Latimore to challenge her medical aid when it came to the reimbursement of her treatment.

She shares: “I was diagnosed with a severe bacterial infection in my respiratory, gastric and urinary tracts. I needed strong antibiotics that had to be administered by intravenous drip. My doctor did not want me to be admitted to the hospital.”

The motivation for out-of-hospital care was simple. First, the COVID-19 virus was spreading rapidly in Gauteng during the time that Mandy required care. A hospital stay would put her in greater risk of contracting the virus (in addition to putting further strain on an already exhausted medical facilities).

Second, the hospitals are not wheelchair accessible for permanent wheelchair users. The bathrooms and toilets in the rooms can’t be accessed or used by wheelchair users. Mandy would, thus, rely on nurses to assist.

“The doctor wrote the motivation to the medial aid stating that it would be easier and cheaper if I was treated at home by a nursing service that could come to my home (which is accessible and where I live alone and isolated) every day and administer the antibiotic through a drip,” Mandy recalls.

“The medical aid gave us the authorisation for the five days. Afterwards, tests were done to see if the infection had been cleared. It hadn’t,” she adds.

Concerned about her recovery, Mandy’s doctor recommended that she do another round of antibiotics – this time for ten days. Mandy shared the information with her medical aid to request authorisation for the second set. Again, they agreed.

“We received the authorisation from the medical aid and tried to get the antibiotics from a hospital pharmacy,” Mandy says.

This would prove a challenge. The intravenous antibiotics that she required were only available at specific pharmacies. The hospital pharmacy was unable to assist. She battled for a further ten days to secure it from the dispensary. However, when they tried to put her request through, it was rejected despite the authorisation provided from the medical aid.

“In the meantime, my health was deteriorating quite badly. I had now developed sino-bronchitis, and was now on nebulisation as well!” Mandy passionately recalls months after recovering from the infections – clearly still distraught by the poor service.

“With much back and forth between the nursing agency, my broker and I drove to the Fourways Life Hospital to try and get the intravenous antibiotics,” she says. This was over the Easter weekend in April, in traffic, while her condition was poor.

Again, she was unsuccessful. Mandy spent her Easter trying to look after herself as best as she could. She says: “I live alone. So, it is not easy when you are very ill. We eventually managed to get them the week after Easter, and the agency administered them for the ten days. This second set of antibiotics worked and I was able to get better. I paid the nursing agency directly for their two invoices.”

In May, Mandy tried to claim the costs from her medical aid. She explains: “I sent both invoices and my authorisation letter to my medical aid to claim for the costs of the nursing services as the medical aid had paid the dispensary directly for the drugs.

“I received an e-mail acknowledging my claim and then waited for the response to be paid back. I only received R1 936 as payment for the first invoice of R3 250, which covered the first five days, and nothing for the second.

“I enquired about their reasons for only paying a portion of one invoice and nothing for the other. The reason that they gave was that the nursing service is out-of-hospital, and the cost of the service was way above their rates,” Mandy says.

The medical aid failed to give a reason for not paying the second invoice. Mandy phoned to challenge the reasoning, explaining that she had received authorisation, but the call centre was unable to assist.

“They stated that they would escalate the issue to their team leader who would get back to me. No response … so, I asked my broker to assist … still no response,” she notes.

After nearly four months of calling with no response, Mandy finally sought out legal advice. She was advised to try one more time with the dispute section of the medical aid before approaching the ombudsman. Following this advice, Mandy made one final call to her medical aid.

“I called again and explained the whole issue, asking for advice. After hanging on for about 20 minutes, the call centre staff informed me that the second invoice had not been paid as the case had been put on hold due to a ‘double claim’,” she explains.

“After proving that I had only sent in one claim with two invoices, the staff corrected the claim and re-submitted it as I had various reference numbers for the queries starting from May. They wouldn’t have done this if there hadn’t been queries as you have to claim within three months of treatment.”

The call centre staff informed Mandy that she would receive a notification of the decision when the claim was processed, but was unable to confirm when the medical aid would pay out. At the time of publishing, the case is still unresolved.

Although payment would be appreciated, the case has become a matter of principle for Mandy, as she points out: “My issue is that I have saved the medical aid a minimum of R57 500 by not making use of the hospital. Therefore, I feel that they should pay the full nursing agency costs.

“It would have cost a whole lot more if I had contracted the COVID-19 virus or any other bug from being in the hospital. I’ve had a pseudomonas infection from a hospital before,” Mandy adds.

In her opinion, a big challenge with querying claims with a medical aid is their reluctance to patch members through to more senior staff. She says: “The problem is that you are unable to speak to anyone higher up from the call centre person to try and reason with them. I had asked the call centre dispute line for the contact details of the personal assistant of the CEO as I would really like to talk to them, but you can’t seem to get any e-mail address or contact numbers for anyone.”

Mandy mentions that some medical aids encourage members to apply for out-of-hospital treatment to avoid patients falling ill with the coronavirus, but her medical aid seems to (deliberately or not) ignore the benefits of at- home care.

“In today’s world with all the computing systems, we can’t get service delivery for any issue that is just a little out of the ordinary. Most systems have become ‘tick-box’ systems. So, if there is something that is a little different the system can’t handle it. Hopefully, this matter will be resolved, I’m not letting it go! It’s not about the money. It’s about the principle,” she concludes.

Mandy is not alone in her struggles. It has almost become an expectation that, at some point, the medical aid will fail to make payment. Approaching your medical aid can be daunting. So, we reached out to Elsabé Klinck, from Elsabé Klinck and Associates, to better understand the best ways to approach a medical aid or scheme.

Rolling Inspiration (RI): From a practical point of view, what is the best way(s) for a member to dispute the reimbursement of a claim by their medical aid?

Elsabé Klinck (EK): The first thing to do is to check the scheme rules and other materials on benefits from the scheme. Note that the fact that something is or is not there is not the end of the matter. Thereafter check whether the scheme has an internal dispute mechanism, or direct the matter to the principal officer.

RI: When would you advise a patient to seek legal assistance to dispute with a medical aid?

EK: Many patient support organisations are able to successfully fight a case on behalf of patient. The legal framework is not difficult. However, sometimes the response by the scheme is of such a nature that one doesn’t know how to take it. It may refer to, for example, “the scheme rules say…”.

Not everybody may know that there is a Supreme Court of Appeal case that stated that scheme rules cannot deviate from the legal framework. In such cases, we would recommend seeking support from persons knowledgeable about the Medical Schemes Act, regulations and rulings by courts and the Council for Medical Schemes (CMS) Appeals Committee. There may already be a ruling that covers one’s case.

RI: Is the patient responsible for the legal fees when opening a case against the medical aid?

EK: Yes. This is no different to seeking any other professional help. Sometimes patient organisations get unrestricted grants from donors and they put that in a “war chest” to fight a case or cases. This can then be used as precedent for other similar cases.

In some instances, doctor groups would take up “in principle” cases on the non or partial reimbursement of treatments that are widely regarded as based on good scientific evidence, and which, for example, save lives or prevent harm.

RI: With Mandy’s case, does she have a solid reason to open a case against on her medical aid?

EK: Yes. There are a few key aspects in her case that indicates where the law might have not been adhered. For example: “It would be easier and cheaper”. Schemes must consider the cost effectiveness if they practice managed care. In other words, they say what treatments can be obtained, when and where. In an important Appeal Board case (C v DHMS case number, 63935), the doctor’s recommended treatment was cheaper, and the ruling was that it was irrational of the scheme to not fund what is appropriate and cheaper.

“The infection hadn’t cleared.” Thus the treatment was ineffectiveness. For medicines, regulation 15I(c) says that, if this is the case, the scheme must make an exception and fund an alternative medicine in full, and without co-payment.

“Double claim.” This indicates that they suspected fraud. However, it should be clear from the medicines used and the care required in order to ensure its administration that there has not been any fraud, and two different medicines were used.

“Not able to speak to anyone.” This is a common complaint, as patients are unable to break through the administrative barriers of their schemes. People at call centres have no discretion at all and are, mostly, not healthcare professionals. So, they would not understand what would be “clinically appropriate”, what would constitute “harm”, etc.

Escalating to the principle officer’s office might be an option, or for the doctor to get in touch with the medical advisor of the specific scheme. Schemes are obligated to ensure that appropriately qualified clinical people manage their programmes. Ethically, those persons must talk to the colleagues who are in practice.

RI: Why should patients consider fighting their medical aid about these kinds of disputes?

EK: The more we keep quiet, the less things will change. How one fights, and with whose assistance, will depend on each case. The unhelpful broker in Mandy’s case is very concerning and I would suggest that such a person be reported to the CMS’s broker accreditation unit.

RI: Do you have any other advice to assist Mandy or others who would like to approach their medical aid about a dispute?

EK: Get the information from your scheme, keep notes and proof of all interactions with the scheme, including the failed interactions.

Understand your condition and why specific treatments or places of treatment is needed. Get your doctor to motivate, keep a copy of all motivations and also interactions between the practice and your scheme.

Break through the administrative barrier the moment that you have to repeat yourself to the same persons or level of persons. Escalate as soon as possible, so as to avoid delays which, in same case, could cause harm to your health. Make this urgency clear in all interactions with the scheme.

To find the contact details of the principal officer for a specific medical aid, follow the link: https:// principal-officers-excel-version/.

The Council for Medical Schemes (CMS) rulings can be found by following the link: https://www. 2030-wpfd-judgements-on-appeals.

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