Cape Town - Medical aid giant Discovery Health say it is unable to pay for cancer medication a Hermanus father needs to save his life.
And it won’t let the client of 14 years upgrade to qualify for the expensive drugs.
His family has requested that his name be withheld.
His youngest daughter said she felt Discovery was letting her father die, despite him having been a loyal member of the scheme for years.
“They are, in essence, murdering my dad. It’s not like he is unhealthy; he is generally a healthy man. I am so frustrated and very sad,” she said.
The family has been with the scheme since 2005, and the father has been fighting the disease since his metastatic melanoma diagnosis in December.
“The oncologists are beside themselves as they say (Discovery) does this all the time. If you read the fine print, it says they cover chemotherapy and cancer up to R200 000 and after that they will pay 80%, and the remaining 20% has to be paid by the family. We have even been raising funds for the 20%. Discovery said he should upgrade, but they declined it.”
Discovery Health chief executive Jonathan Broomberg said: “All plans on Discovery Health Medical Scheme cover all cancers, including this patient’s condition. However, the plans vary considerably in terms of which medications are covered for cancer.
In particular, certain very high-cost treatments are only available on the Classic Comprehensive and Executive plans.
This member’s plan excluded cover for the specific medication being requested. This medication is Keytruda, and is a very high-cost medicine that is covered only on the DHMS Comprehensive and Executive plans.”
Broomberg said Discovery had received requests to upgrade the plan, but said the medical scheme rules prohibited any upgrades of plans during the benefit year.
“This long-entrenched rule is important to prevent anti-selection. If the scheme allowed mid-term upgrades, the implication would be that all members would downgrade to the cheapest plan, with the lowest benefits, and then only upgrade as and when they need the benefits.
This would have a negative impact on the long-term sustainability of the scheme and would increase premiums for all members. The scheme applies these rules in a consistent way to all members.”
The daughter said the rule was “unethical and immoral” and feared for how many other people had died as a result of being rejected.
The patient’s oncologist said they had pleaded numerous times with the medical scheme to upgrade the patient’s plan because his condition continued to deteriorate.
Due to the delay in Discovery allowing the member to upgrade to pay for the treatment “we have restaged him with another CT scan".
"This scan shows the progression of disease with new metastatic areas. This is clearly now a visceral crisis and the patient urgently needs systemic treatment”.
The oncologist said Discovery had sent the patient’s plan for Keytruda to its oncology review committee.
“We have spoken to them again and they have said they will give feedback. This is hopeful, as the RSA oncology review board has already reviewed the plan and feels Discovery should pay for it. We hope to hear good news from them soon.”