Johannesburg - A Joburg woman has temporarily lost the use of her left leg while Discovery Health Medical Scheme quibbled over whether to pay for her surgery.
Forty-three days ago, Beverley Smith, 58, started experiencing pain in her lower back while on holiday with her husband Basil in Scottburgh, KwaZulu-Natal. After going to see a GP, she was urged to see a specialist.
Fast-forward to July 5: Beverley was admitted to the casualty ward at the Life Bedford Gardens Hospital, where an MRI of the lumbar spine and an X-ray were conducted.
The results of the MRI, seen by The Star, revealed that a disc between the vertebra in lumbar 3 and 4 had herniated into the spinal column, and was effectively squashing the spine and weakening the nerve root to her left leg. Immediate surgery was recommended.
But despite neurosurgeon Dr Percy Miller and an orthopaedic surgeon writing letters of motivation to Discovery stating that Beverley needed urgent surgery to insert a U-device (an interspinosal stabiliser and fixator) in her spine and a decompression – and her being considered a premium minimum benefits patient – the medical scheme refused to authorise the surgery.
By mid-July, Beverley’s condition had started becoming progressively worse. Her left leg had weakened significantly, resulting in her not being able to walk on it.
In one of several letters Basil wrote to Discovery pleading for them to authorise the surgery, he stated: “My wife is unable to dress herself, she can’t bend down sufficiently to pull on her stockings, she is in constant agony, she is taking massive amounts of painkillers and anti-inflammatory medication, she has to sit on her right buttock…”
However, the authorisation for the surgery was declined and the scheme recommended that she rather undergo six-month “conservative treatment” (non-surgical treatment such as physiotherapy and medication).
When The Star visited Beverley, she was bedridden, a white bucket stood beside her bed for when she was overcome with nausea, and several boxes of pain tablets were spread across the dressing table.
Miller told The Star: “Anywhere in the world, a patient with this condition would have an operation. Discovery is an awful, unethical scheme that manipulates doctors and patients. It’s nonsense that Beverley should have six months’ conservative treatment. Her leg is getting weaker and she could lose the use of it (permanently) without surgery.
“Discovery turn down patients when they think they can get away with it… They have a sort of social discrimination and it’s disgusting.”
On Sunday, the Smiths were not aware that Discovery had made a decision to review the procedure.
“Up until this moment, we have not had this confirmation or been informed,” Basil said.
He said Beverley had received a call from a woman from Discovery on Friday, who said there had been miscommunication and that the scheme was trying to contact the orthopaedic surgeon who had treated Beverley, but he was not available until Monday.
“I expect Discovery to explain quite clearly in public why they have chosen to take the route they have,” Basil said.
Discovery does about-turn
Responding to queries from The Star on Friday, Discovery Health chief executive Dr Jonathan Broomberg explained that the scheme provided for cover of spinal surgery according to the benefits of a member’s specific plan type and that, in some instances, these benefits were also subject to defined clinical guidelines.
In the case of spinal surgery, he added, the guidelines applied by the scheme were based on those of the South African Spinal Society.
“In Ms Smith’s case, the request for funding for the spinal surgery using the interspinous device was declined as Ms Smith did not meet the criteria in the guidelines. Please note that this does not imply that all spinal surgery was declined, but only the use of this specific device.
“It is also important to point out that according to the medical reports received, Ms Smith’s condition is not a prescribed minimum benefit condition, and the scheme is thus not obliged to fund this treatment, which falls outside of the established guidelines,” he said.
However, in an about-turn on Sunday, Broomberg told The Star they had received “updated clinical information from a different treating doctor” and would now be funding the surgery.
The Star