Below is a personal account from a cancer sufferer who is struggling with the medical aid system. Having had the disease for 19 years, she refers to the continual frustration doctors are having when having to re-motivate for various forms of treatment. She does however refer to a mistake she may have made when changing to a Hospital Plan and paying for the check ups herself, but argues that this is what they tell you to do. This is her story.
From Rose Maytham
It seems the confusing world of Medical Aids has become even less user-friendly: it appears my health is not conforming to my Medical Aid Rules.
It is law in South Africa that Medical Aid companies pay for cancer treatment, but lurking beneath the rules of the medical aid companies is another layer of ways in which they can bully you and wriggle out of paying for medicines that will put you into remission or save your life.
The process is daunting, especially when one is running on about 35% power.
The “rules” state that if you have been a member of the medical aid and have previously been treated for a condition and previous medication has worked, then according to The Council of Medical Schemes Regulation 15, you should be allowed treatment again.
Oh, but stop! For some reason I was taken off the Oncology program although I didn’t die and I remained a patient with 3-monthly or slightly longer interval check ups.
It appears the mistake I made was to change to a Hospital Plan and to pay for my check ups myself. It tells you in the Marketing brochure that you need to do that. I still don’t know why I was taken off the program. Perhaps too long in remission?
I have had Chronic Lymphatic Leukemia for 19 years and I have been a member of Liberty and the company they took over, since 1996.
Whilst working I was able to afford Platinum Complete with Savings and my saving portion was continuously used for my treatment when it should not have been, but that issue was never resolved. Therefore, on retiring, it made sense when the Liberty broker suggested that Hospital Standard with Top Up and Gap would cover me very well. That is what I have, but Top Up does not cover pre-existing conditions. Gap, because I took the Liberty offering, doesn’t cover me if Liberty refuse any part of the treatment.
Be very aware of this.
Now that I have the misfortune to have come out of remission and my life is precarious to say the least, I have to battle through the “Rules” that are not available in the marketing brochure. For example, why is it that Liberty Medical Aid and Metropolitan?? are the only two medical aids that don’t supply the medicine I need? The supposed LMS or MMRP for Hospital Standard is R221,000 annual limit; this, however, will not include the recommend treatment suggested by my Professor. I have checked with the two medical companies who supply the drugs and obtained the prices. Nowhere near the annual limit!
The first rejection was because, someone wanted me to have another bone marrow biopsy. Do you think that the professor wouldn’t have done this if it was really necessary? They are very painful to say the least.
The refusal was reversed when I explained that the other tests were sent, which the oncology department of Liberty hadn’t ‘seen’ but, amazingly they found them “underneath the other result”, and I was allowed back onto the Oncology program. It is beyond my comprehension that Liberty Medical Aid scheme makes oncology patients’ lives more difficult while knowing that they are coping with a potentially life and death situation.
The second and third rejections of the medication followed quickly thereafter. Needless to mention that they are specifically for Chronic lymphatic Leukemia, recommended by the FDA and the South African Medical approvals.
Over the last few years I have met a lot of patients experiencing the same problems. A lot of them just give up, because they don’t have the strength or ability to pursue and fight for their rights. Guess what? They die and hence no more problem for Liberty!
Can you imagine the utter frustration for doctors and specialists, who have to continuously use their very valuable time to remotivate to get some form of treatment for their patients. Soon they won’t have any time at all as more and more doctors leave our shores.
I recently read an article by Media 24 on a survey of medical aids. Guess where Liberty came! Yep at the bottom.
