"Sorry Mrs Nancy Soller your medical aid does not cover the treatment for your type of cancer”. This was the devastating message relayed to Nancy Soller.
Cancer patient advocates, along with cancer advocacy group, Campaigning for Cancer, say now is the time for medical aid members and cancer patients to choose their benefits for 2012.
Every year many medical aid members over-look those “unnecessary” emails or printed documents asking them to review their current plan and medical cover. But with the burden of cancer being so high, and cancer treatments often being costly, medical aid members and cancer patients cannot afford to be complacent about the medical aid plan they purchase. This is the message cancer advocacy group, Campaigning for Cancer want South Africans to hear.
The major medical schemes offer their members the opportunity to do so for a short period between 9th – 30th December 2011. Post these dates, upgrading in order to receive better cover for cancer treatments is not possible again until December 2012.
South Africans may make decisions on medical cover without knowing what that cover actually entails. Members often don’t consider what the costs of cancer treatments are, how much cover is afforded, what the terms such as “exclusions” and “biological therapies” mean, and how they affect medical cover.
“The last thing a cancer patient or their family members want to hear is that the treatment prescribed by their oncologist will not be paid for by their medical aid. I have had personal experience of this and have seen many of my fellow cancer patients go through the same thing”, said Beverly Baxter, a breast cancer patient from Kwa Zulu Natal.
“Campaigning for Cancer regularly gets calls from cancer patients whose medical aids won’t pay for their treatments. We realized that this is becoming a big concern and want to encourage more patients and their families to share their experiences so we can get a clearer understanding of how we can educate and equip medical aid members better in their decisions about cancer cover”, said Campaigning for Cancer CEO, Lauren Pretorius.
“Cancer patients who would like to share their medical aid experiences can do so on the Campaigning for Cancer mini website, which focuses on cancer medical aid cover”, she added.
Jeannick Langeveld has been advocating on her husband’s behalf for his lung cancer treatment on a number of occasions. “What patients and their families need to realize, is that there are exclusions for some treatments. If we had know this prior to my husbands cancer diagnoses, we could have put other options in place like gap cover or dreaded disease cover.” she said.
Being Informed: what members should know
Although there are various options available, a decent oncology benefit could consist of an overall annual limit of about R300 000 to R400 000 per beneficiary.
Members should be aware of benefits that promise “Unlimited Cover” as this often is not the case. Often the scheme rules exclude many of the newer cutting edge treatments which tend to be more costly than standard chemotherapy, despite the fact that they have been approved by the Medicines Control Council (MCC)
Some scheme’s lower benefit options offer between R 90 000 or R150 000 cancer cover per family. With this amount of cancer cover, members will only be provided with treatment in line with prescribed minimum benefits( PMB's) which are equal to what you would have received if you went to a government hospital for your cancer treatment or care.
The cost of medicines used in oncology is often the main problem members’ face when trying to get medical schemes to cover the treatment plan recommended by their doctor. Many scheme’s rule even state that newer cancer medicines are excluded on certain plans. As a result, members have to pay for these medicines out of pocket. These newer medicines, often referred to as specialized medicines or biologics, do not have a generic alternative and some of them can cost anything between R100 000 to R500 000 for their prescribed.
Members should also be clear about payment for consultations to oncologists or other specialists and check whether their scheme limits the number of visits to a specialist and how much is allocated for specialist consultations.
Know schemes decision about treatment
Campaigning for Cancer suggests cancer patients should also insist on knowing if the scheme’s decisions about their treatment are made by oncologists and not by professionals who may not necessarily have the required expertise in oncology. This is because in some cases schemes appoint a managed care company to manage their protocols and determine if patient’s treatment is in line with the set protocols.
According to Section 41(1)(a) of the Medical Schemes Act No. 131 of 1998, medical aid members are entitled to ask to see their scheme’s treatment protocols, rules and exclusions and according to the Consumer Protection Act they also have a right for all these things to be provided in a language and manner they understand. “Don’t be afraid to ask for clarification if you are not understanding what is being said. Keep asking until you do understand”, said Pretorius
The scheme rules, protocols and formularies differ between the benefit options on a specific scheme and from scheme to scheme. Campaigning for Cancer says members should get all the information they need to make an informed choice before signing on the dotted line.
“People often take the easy route out by just continuing with their current medical aid plan and sometimes even opt to reduce cover in order to save an extra couple of Rands. “Medical cover has become a necessity in our modern environment, the burden of cancer is high and we want people to look more closely at whether they can afford not to be appropriately covered for a cancer diagnosis and treatment.
“With many of the larger schemes allowing you to upgrade and downgrade at this time of the year, we urge you to assess your 2012 cancer benefits now. It’s advisable for members to query the cut-off dates it with their scheme directly,” said Pretorius.
(Press release, Matrix Advertising and Communications, December 2011)