With reference to the letter “Cutting kids’ benefits will cost us more” (9 February, 2012) in which Dr Claudine Storbeck voices concerns about modifications to Discovery Health’s allied and therapeutic benefit for 2012, I state the following:

The allied and therapeutic benefit limit has been instituted to curb abuse in this area, to the benefit of all scheme members, as well as healthcare providers. Discovery Health has identified an increasing trend towards the abuse of certain day-to-day benefits.

While these services are often used appropriately for serious clinical conditions, these benefits are increasingly being exploited for services that are not clinically justified.

Rather than set a sub-limit for each area of care, the benefit now makes provision for a basket of care, subject to an overall limit, that members can allocate to one or more area as they need cover.

The allied and therapeutic benefit covers the vast majority of our members in full, because we have set the benefit limit to cater for more than 97 percent of our members, based on current benefit usage patterns.

For those needing additional cover above these limits, an extender benefit automatically provides unlimited coverage for specified clinical conditions requiring extensive treatment. The benefit is flexible enough that any member is entitled to apply for these unlimited benefits if they believe that they are clinically required.

Furthermore, additional steps have been taken to address concerns expressed by members and healthcare providers around members with conditions that require access to additional benefits above the limit but whose conditions do not automatically qualify for the extender benefit.

In these cases Discovery Health and representatives of the relevant professional society will review the clinical circumstances of every member who reaches the allied and therapeutic benefit limit to evaluate whether they require access to further benefits.

Any such member deemed to have genuine clinical need will gain access to additional benefits.

Discovery Health is fully supportive of the vital role speech therapists and audiologists play in providing vital healthcare to our members. Evidence of this commitment is the recent establishment by Discovery Health and the SA Speech-Language-Hearing Association of an advisory board, consisting of experts in this field, to review the individual cases of scheme members who have reached 80 percent of their benefit limit.

We are also in discussions with the association about specific protocols applying to specific groups of children who may require ongoing therapy and can be pre-qualified for these.

It is our intention to identify groups of children where therapy is clinically appropriate and effective, and our members should rest assured that these children will remain fully covered for the therapy they need.

We will be guided by the advice of the association on these matters, and will update all therapists treating our members of progress in this regard.

Dr Jonathan Broomberg

Chief executive officer

Discovery Health