Medical scheme misery

“AND can I just confirm the main member’s ID?”

The words “main member” give me – and a number of my women friends – the chills. It’s a reminder that we are still living in a patriarchal society, where the husband is regarded as the breadwinner, and wives as his dependants.

Like many other couples, my husband and I share household costs pretty much equally, but the medical scheme continues to address all accounts, queries, rejections, whatever, to his email address, so that we are constantly disentangling who is responsible for which blood test that has been rejected for payment. I have asked on every occasion possible that my accounts and queries be directed to me, but the schemes just don’t do this.

I call them schemes on purpose – in my jaundiced view, the term is more descriptive of what they do than ‘aid’, which very often is not easy to wrangle out of them at just the point when you need it.

A friend of mine has just emerged from a long and very dark tunnel. He has been treated for cancer, and not long ago, discovered that the treatment was unsuccessful – his cancer had metastasised.

There were two options: standard chemotherapy which held the sure prospect of death within two years or less, and one very promising new treatment option which all research indicates very likely would mean a much longer lifespan. But of course the medical scheme simply refused to pay for it, even though the costs involved are much of a muchness.

And so began the battle. And ultimately, my friend, backed by his doctor and a patient advocate, negotiated a way through this thicket. But I found it exhausting just hearing the accounts of the arguments; I cannot begin to imagine what it was like for a man who is facing a sentence of death, who was aware of the precious days trickling away as the cancer stealthily seeped into parts of his body where it had not been before. How exhausting, how debilitating. How counter-productive.

On Monday last week, a doctor recommended therapy for someone I know – she’d need about ten to twelve sessions. I spent some time on the phone, helping her to pin down whether or not her medical scheme would pay for this. (The answer? Yes – but only six treatments. Not enough to be helpful. In the same vein, schemes say you can have six sessions of physiotherapy after an injury, when you really need eight or nine – so that six months later, you return to the physio with a shoulder or knee in bad trouble, and you have to pay for the whole lot yourself.)

My mother was told that the spectacles she needed, authorised on January 11 by the medical scheme (on a new, more expensive option, because R*** Health dumped the more affordable one she had been on), were not covered because her cover had, in some way, been exhausted. How is this possible, not even two months into the year?

I have just wrestled with the R*** Health benefit schedule for 20 minutes (that’s on top of 20 minutes spent trying to download it online, and then phoning the scheme for a copy).

Why is the text next to impossible to understand? Why do these pieces of obfuscation art include eccentrically punctuated sentences, dotted with terms that seem to have no definition: “REMEMBER your self payment gap accumulates at scheme rate, not cost and needs to be reached before you can access your threshold benefits”?

Here are some things you might want to REMEMBER yourselves, medical schemes:

REMEMBER that you are interacting with people who are very likely to be under grave stress and physically debilitated; raising their blood pressure and making their bodies pump excessive stress hormones is unlikely to improve their state of health.

Incomprehensible brochure babble

REMEMBER that few of us have the comprehension and legal skills to understand the brochure babble about Above Threshold Benefits and Self Payment Gaps and scheme rate and the like. (Many of us seem to believe you make it purposefully difficult to negotiate your rules, so we’ll give up and go away when payments are rejected.)

We can’t figure it out on a good day when life is smooth sailing, so you could work a bit harder at making it all simple and understandable for those bad days when the member’s just been referred for major surgery or been told their child has an incurable condition.

Oh, and we all have lives too, you know; we should, by rights, be allowed to invoice you for those hours battling your phone system and your staff!

REMEMBER that the bulk of the membership are neither dishonest themselves, nor responsible for the dishonesty of certain healthcare practitioners.

Despite the nice things Minister Pravin Gordhan said in his Budget Speech about National Health Insurance, despite my understanding of the obstacles Minister Motsoaledi faces, my faith in NHI is fading – not because I don’t believe universal health is the way to go, but because implementation in South Africa’s current toxic environment is unlikely to achieve its goals.

So, as Gloria Estefan sings, “con los años que me quedan por vivir…” (over the years I still have left to live), I am likely to be struggling with medical schemes in one form or another. Please, please, can all stakeholders work together to make the industry more straightforward, and yes, kinder?

* Mandi Smallhorne is a versatile journalist and editor. Views expressed are her own. Follow her on Twitter.

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