Johannesburg - A decision not to fund a particular treatment for a cancer patient was based on an expert panel's advice, Discovery Health said on Thursday.
“Evaluating new health care treatments is complex, and Discovery Health Medical Scheme's approach is to defer to the leading independent experts in the field to ensure that the care our members receive is the best and most appropriate,” it said in a statement.
Health-e News Service reported on Thursday, as published in The Star, that Thobeka Xaba, 23, a Discovery member, had not had chemotherapy since March 25 because the medical aid refused to pay for the medicine her oncologist recommended.
Dr Daleen Geldenhuys told Health-e that if she used Doxorubicin, Discovery's recommended drug, she had up to a 40 percent chance of suffering heart failure.
“So if the medical aid has a heart ready for a transplant, then I will give it to her because the regimen they want me to give my patient will damage her heart,” she was quoted as saying.
Geldenhuys said Xaba had an inoperable, aggressive tumour.
Discovery said that during an appeal hearing with the Council for Medical Schemes (CMS) on Thursday, Geldenhuys conceded that Discovery's recommended treatments were acceptable.
According to Discovery, Geldenhuys told the appeal hearing Xaba had been on treatment the whole time.
The medical scheme said it had referred Geldenhuys's recommended drug, Paclitaxel, to a panel of leading academic oncology specialists for advice.
“The feedback from this panel was clear - that there is no published clinical evidence that the drug would be effective or safe for this patient's condition.”
In addition, the panel found there were other safe and effective treatments, which the medical aid would cover in full. The scheme would have covered more expensive treatments for Xaba, which were supported by clear evidence.
“Importantly, the decision was not a financial one, but one that places Ms Xaba's health as the top priority,” Discovery said.
Earlier, the CMS said the medical scheme and Xaba had settled the dispute about payment for her treatment.
“The parties have settled.... A full report will be released on Monday, once full details are received,” CMS spokeswoman Elsabe Conradie said.
Health-e reported that Discovery wrote a letter to the CMS on May 31, saying it would not pay because it was not a benefit covered in Xaba's selected plan type, and the treatment was not the level of care available in the public sector.
In June, the council ruled against Discovery, but it wrote back two weeks later saying it would appeal.
Sapa