Johannesburg - A medical aid company is refusing to cover intensive care treatment for a premature baby – because he weighs less than 1kg; deemed the threshold at which survival chances are slim.
One of the quadruplet’s siblings has died.
The babies were born prematurely to Chantel Emery, who is quadraplegic and lives on the West Rand.
According to TopMed’s policy, the boy who weighs less than 1kg will be entitled only to “minimum coverage”.
This minimum coverage does not include ventilators, which are vital in helping many premature babies survive, because they often can’t breathe on their own.
The quadruplets’ father, Robert Emery, said: “They are basically telling me: ‘We will decide that your child is not going to make it’.”
The other two children will be given full coverage under the government’s legislated prescribed minimum benefits provision in the Medical Schemes Act.
Because the medical aid won’t cover the full treatment for the surviving babies, and because the couple have racked up bills of more than R1 million at the Life Flora Hospital, the infants may have to be moved to a government facility.
Robert said on Friday: “They can’t be moved because they are on a ventilator… if they are moved, the chances are that they will pass away.”
The Emerys face the prospect of their hospital bill reaching R5 million. The four boys – Bradley, Daniel, Gabriel and Harvey – were due in September, but were born on June 28 at the couple’s home after Chantel went prematurely into labour.
Her 13-year-old stepson, Joshua Binns, alongside his father, helped to deliver the boys.
Bradley died on July 14 from a blood clot in the head. His heart had stopped beating.
According to Robert, last year he and his wife shopped around for medical aid that would provide for the needs of their large family. Friends recommended TopMed.
Robert said he approached an insurance broker and everything was handled over the phone. To his knowledge, he and his wife had asked for an uncapped hospital plan option after being told by doctors in February that Chantel was carrying twins.
“I specifically mentioned to (the broker) when I spoke to him that I’ve got a big family.
“It’s me, my wife and four children, and we’re looking at having another kid.
“My wife asked specifically for the uncapped option because that would cover everything.”
His wife signed the papers in March, and in April he phoned once again to check that the medical aid would cover all the children, Robert said. They were guaranteed that it would.
But Robert said the situation changed a week after the boys were born. The hospital informed the couple that the medical aid would pay only up to R1m.
Robert said that as it was, on the day they were told, they had a bill of R790 000 for the 10 days the boys had spent in hospital.
“We were shocked and said, ‘hold on a minute that’s not what we signed up for’.
“So now that puts my children in danger. The possibility is that another baby could die now.”
The couple have since gone the legal route and have penned a letter to the broker, giving him three days for the matter to be sorted out.
Robert said that his advice to the public was to check the fine print. “Everyone wants the best care for their loved ones. Ask what (your medical aid) won’t cover.”
Chantel added: “Never do it over the phone.
“Make sure it’s recorded.”
The couple have also begun fund-raising initiatives to help meet their staggering bill.
“People have indicated their willingness to help,” said Chantel.
Those seeking to assist, may do so on the Emery’s Facebook page – the Awesome Foursome Emery Boys.
Council for Medical Schemes spokeswoman Dr Elsabé Conradie said that, while there’d been many similar cases involving newborns that the council had dealt with, the Emerys’ case was unique.
“Each case is dealt with on its own merits.
“Mr and Mrs Emery should first take the matter up with their medical scheme.
“If they are not able to receive a satisfactory resolution, they should contact the Council for Medical Schemes’ Complaints and Adjudication Unit.”
Asked whether TopMed was obliged to cover the full hospital expenses of the children, Conradie said that parents should ensure that they are covered once registered. There is a time frame of up to four months after birth to submit claims to a medical scheme. It is critical, however, to register the baby as soon as possible after birth.
She said that, while it appeared that the bill should be paid in full by the medical scheme, the council could not comment further, as it didn’t have all the facts.
TopMed has been contacted, but has yet to comment.
The Star