Feeling cheated by doctors

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Cape Town - In response to the ongoing debate on Fin24 about reasons for the high costs of private hospital care, Fin24 user Michael tells of his negative experience with doctors, hospitals and medical aid payments during his wife's treatment for breast cancer. He writes:

My wife had cancer. At first, before she was diagnosed, we had to pay for everything until they did the core biopsy. We had that done at a state hospital in Johannesburg.

Only after the results came back as positive for stage three breast cancer did the medical aid start to pay.

She had to go for chemotherapy at an academic hospital which also forms part of a private hospital group.

When we saw the chemotherapy doctor for the first time we mentioned our lack of money. She said she does not work with the money, but that she charged medical aid rates.

We ended up paying her in the region of R350 to R400 per visit after the medical aid had paid their share.

If I remember correctly, my wife had to see her 16 times over a six month period. Add that up. On top of that she one day suddenly told us she is going on holiday to Greece.

READ: Two sides to private hospital care

The next step was the operation at another private hospital. It was done by a surgeon and a reconstruction surgeon. There was also a pathologist that we were under the impression the medical aid would pay for.

The account balances we were left with after surgery included about R4 500 for the surgeon, about R12 500 for the reconstruction surgeon and for the pathologist about R6 000 or R7 000.

Medical aid paid the hospital stay and theatre in full.

The next step was radiology.

My wife was given a choice of a male or female radiologist and two locations. Neither of the locations was close to our home and when we asked about the one near our home we got a funny type of grin from the doctor.

So, we were then referred to a doctor who charged us R980 for the first consultation and then they also put through a claim to our medical aid.

We then decided to get a second opinion and it turned out all the radiotherapy machines need to be at the same standard.

The treatment at the centre nearest to us would, therefore, have worked just as well.

The new doctor also charged only medical aid rates. So we didn't have to pay a thing.

I personally think the problem is our doctors are ripping us off.

I cannot tell you how many times we felt lied to and how many times we had to go and chat to the doctor for no good reason.

The problem is that you don't say anything, because these people are going to save your life.

You then end up not saying anything and doing everything they tell you, because they supposedly know best - or so you think.

Health journalist Susan Erasmus offers some insights on the issue of breast cancer and medical aid:

If one is a medical scheme member, you need to find out exactly what your scheme will pay for, and what it won’t regarding breast cancer.

Treatable breast cancer is a prescribed minimum benefit (PMB), but not all cancers are. In other words your scheme has to pay for the diagnosis, treatment and care costs of your breast cancer, whatever medical scheme option you are a member of.

This would include surgery, consultations, radiology, pathology, chemotherapy and radiation therapy, according to the Council for Medical Schemes.

Most medical schemes will pay for one mammogram per year and scheme members are encouraged to use this benefit.

Erasmus also suggests finding out if your scheme will pay for the BRCA gene test.

"The earlier a cancer is detected, the greater the chances of successful treatment," says Erasmus.

If you have cancer of a solid organ that is treatable, it qualifies as a PMB if it can be treated.

This means that it hasn’t spread to adjacent organs, or to distant organs, or caused incurable damage to the organ in which it has originated.  (Medical schemes will pay for treatment of some systemic cancers, such as leukaemia if it is listed as a PMB.)

If the cancer has spread to the rest of your system, but it can be proved that at least 10% of people with the same severity of cancer have lived longer than 5 years after treatment, your cancer will be treated as a PMB. If not, the oncology limit on your specific option will kick in. This depends on your scheme, and the option you have chosen.

Schemes will generally carry the cost of cancer medication used by the state to treat cancer.

- Fin24

Disclaimer: All articles and letters published on MyFin24 have been independently written by members of the Fin24 community. The views of users published on Fin24 are therefore their own and do not necessarily represent those of Fin24.

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