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Cancer and your medical scheme

Apr 26 2015 16:30
Susan Erasmus
Cape Town - Most medical scheme members assume that if they were to be diagnosed with cancer, their medical scheme would foot the entire bill for their treatment.

That is not what this Fin24 user experienced. Here is the letter that was sent to us.

"I have bone cancer and I have had several operations because of this condition.

'My medical aid has recently advised me that I am not to be considered a PMB (prescribed minimum benefits) patient, as the operations were for as they called it secondary ailments.

'In my case the cancer originated in my right kidney and then spread in my body. Operations were required for this, to rectify the situation where the cancer attacked my bones in arm, leg etc. This they regard as secondary and they state that it does not qualify for PMB status and obviously payments for treatment.

'Please advise, as this has a major financial implication."

Here are some questions and answers below that should answer this reader’s questions and yours with regards to cancer, your medical scheme, and what it will cover:

Do most medical schemes have a cancer benefit?

Yes, they do. That is the so-called ‘oncology’ benefit. It is often fixed in rand terms, varying from between R100 000 to R400 000 on more comprehensive schemes.

What happens if I exceed this limit?

If your cancer is a Prescribed Minimum Benefit (PMB) your scheme has to continue paying for treatment regardless of whether the oncology benefit has been exhausted or not. If your type of cancer is a PMB, the scheme has to pay for treatment at cost.

When is cancer a PMB?

Cancer of the solid organs (such as the liver) qualifies as a PMB only if it can be treated. If it cannot be treated, even if it has not spread beyond the organ in which it originated, it is not seen as a PMB, and a scheme does not have to pay for its treatment as a PMB. Oncology benefits still apply though.

If my cancer is a PMB, what does my scheme have to pay for?

These services can include  consultations, surgery, specialised radiology, pathology, chemotherapy and radiation therapy. Do check whether your scheme option requires you to use particular service providers.

What about something like leukaemia that is not located in a solid organ?

There are various cancers of non-solid organs and sytems that are PMBs, such as lymphoma, myeoloma and leukaemia. Check with your scheme what is covered as PMBs.

When is a cancer thought to be treatable?

If it has not spread to adjacent organs or to distant organs, or it has not yet done incurable damage to the organ in which it originated. Also, if there is evidence that more than 10% of people with a similar condition have lived for at least five years after treatment, the scheme will pay.

So if my medical scheme doesn’t think my cancer is treatable, do I have no cover?

No, your oncology limit on your scheme will pay for all oncology-related diseases that are the result of a non-PMB cancer. If something like chemotherapy is not listed as a PMB for your particular kind of cancer, this treatment will be paid for from the oncology benefits, and not as a PMB. If this limit has been exceeded, schemes can refuse to pay for secondary ailments resulting from non-PMB non-treatable cancers.

Can my scheme have a say in my cancer treatment?

The scheme is allowed to use protocols (certain guidelines) to manage your cancer, but the scheme has to pay for treatment that is regarded as a minimum standard in state hospitals. This does not mean you have to go to a state hospital – what it means is that if the state pays for 6 cycles of a particular chemo drug for state patients with your type of cancer, your scheme must fund this same treatment or medication in a private hospital or at a designated service provider (DSP) depending on your scheme option. If you opt to use more expensive medication than that used in state hospitals, you could be asked to pay the difference (co-payment).

Do I have to join my scheme’s cancer management programme?

Yes. In this way the scheme can keep up to date with the success of the first line of treatment, and it can also ask the treating doctor for updates on your response to treatments and the stage of your cancer.

Do I have to get pre-authorisation for cancer treatment?

Yes, you do. Before you go for any treatments, contact your scheme. They will also be able to give you an indication of exactly what they will fund.

What happens if my oncology limit runs out?

Most schemes will carry on paying, but can request a co-payment of 20% from you. Check with your scheme what the case is on the option you have chosen. A scheme can legally request that a patient be placed in a state facility if all benefits have run out and the patient cannot make any co-payments. Any patient can apply for ex-gratia (over and above usual benefits) from a scheme, but schemes consider these on a case-by-case basis and are under no obligation to grant this request.

What if I become terminally ill with cancer?

Most schemes and hospital plans have made provision for hospice care. This is either for a rand amount (anything from R10 000 to R40 000) or by a number of days (anything from 10 upwards). Do check what your individual option benefits are for this.

* Susan Erasmus is a freelance writer

(References: The Council for Medical Schemes; medicalaidcomparisons.co.za; Discovery Health; Fedhealth)


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