Even cheapest medical aids must pay for treatments not offered by state - Court

148 days ago

It’s almost as if they [medical schemes] set the whole thing up to create all these hoops and loops to jump through so that they don’t have to pay.

Kieno Kammies, presenter - CapeTalk

A court ruling has empowered consumers to force their medical aids to fund any drug or medical care a doctor considers necessary to treat any disease that falls under the “Prescribed Minimum Benefits”, a basic basket of care.

Discovery Health Medical Scheme lost its case over its refusal to pay for a member’s glaucoma implant, despite a specialist recommending the operation.

The scheme, which would have paid for treatment twice the cost of the device, argued that clinical evidence around the implant was weak.

It also argued it was legally entitled to refuse payment for the device because it was not available in state hospitals.

The industry is now compelled to pay treatments not offered by the state if recommended by an appropriate medical professional.

Kieno Kammies interviewed Thembekile Phaswane (Senior Manager, Council for Medical Schemes) and Dr Tim Modupe (Head of Clinical, Council for Medical Schemes).

This case doesn’t just open floodgates. You look at clinical appropriateness of the treatment… in this case, it was founded that the recommended treatment was effective…

Thembekile Phaswane, Senior Manager - Council for Medical Schemes

There needs to be a comprehensive preventative and primary healthcare component to future PMBs… to help us discover illnesses earlier when they can be treated more effectively and for cheaper…

Dr Tim Modupe, Head of Clinical - Council for Medical Schemes

For more detail, listen to the interviews in the audio below.

This article first appeared on CapeTalk : Even cheapest medical aids must pay for treatments not offered by state - Court



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