A phone call from a stranger in the middle of the night informing you that your child has been injured in a road accident is every parent’s nightmare. Eileen du Toit was told that the car her 20-year-old son, Mathew, was driving had left the road and rolled several times.

An ambulance was called and Mathew was taken to the casualty department at Milnerton Mediclinic in Cape Town just after midnight. He was vomiting, and the doctors recommended X-rays.

He was given an intravenous painkiller and placed under observation for two hours. When no fractures or acute injuries were identified, he was discharged.

Du Toit submitted the ambulance and casualty accounts to Discovery Health Medical Scheme (DHMS), but was surprised when, except for the ambulance account, the expenses were paid from her medical savings account. She had expected the treatment to be classified as an emergency, which, as a prescribed minimum benefit (PMB), the scheme should, by law, cover in full.

The PMBs include all medical emergencies, 270 listed conditions and 25 common chronic illnesses.

Du Toit raised the issue with the scheme’s administrator, Discovery Heath. A consultant said she had to pay for the X-rays and treatment, because the codes on the accounts indicated that neither had been performed during an emergency.

The consultant said the scheme’s rules required that a patient be admitted to hospital for a procedure to qualify as emergency treatment.

Du Toit appealed to the scheme’s principal officer. She was referred back to the administrator, where a relationship manager confirmed the information provided by the consultant.

He told Du Toit that a procedure performed in casualty was classified as a PMB only when the condition was considered to be “a life-threatening emergency”. He said the diagnostic and treatment codes on the accounts indicated that her son’s condition did not qualify as an emergency as defined by the PMB regulations.


‘Incorrect interpretation’

Medical scheme activist Angela Drescher (see "Discovery rejects claim of 'pervasive misinformation'"), who became aware of Du Toit’s situation via social media, said DHMS’s decision was contrary to the principles set out in the March edition of CMScript, a Council for Medical Schemes publication aimed at educating members about their rights.

Drescher told DHMS that its interpretation of the definition of an emergency was incorrect, and it was entirely liable for Du Toit’s accounts. She pointed out that:

• You don’t have to be admitted to hospital for treatment for an emergency condition to qualify as a PMB. You can be treated in any “clinically appropriate setting”.

Drescher said her husband had been treated by paramedics on a golf course, and she had succeeded in having all the expenses associated with his treatment paid from DHMS’s risk benefits, not her medical savings account.

• The consultant and the relationship manager had cited a truncated definition of an emergency. Drescher said that, in terms of the PMB regulations, a condition is an emergency if the failure to treat it immediately could result in one of the following three outcomes: serious impairment to a bodily function, serious dysfunction of a body part or organ, or death.

• The CMScript quotes the PMB code of conduct (see "An emergency that turns out not to be one is a grey area") as stating that, where a condition has been confirmed as requiring emergency treatment but has not been confirmed as a PMB, a medical scheme should cover the costs until tests confirm that the condition is not a PMB. This means the scheme should pay for any consultations, tests or scans that were required to diagnose the condition, as well as any treatment up to that point. Once a non-PMB diagnosis has been confirmed, any further medical interventions will be covered in terms of the scheme’s rules.

As a result of Drescher’s intervention, the relationship manager conceded that he had made a mistake, and DHMS paid the accounts from its risk benefits, as the scheme is required to do for an emergency PMB condition.


Insufficient information

Asked to explain the scheme’s about-turn, Milton Streak, the principal officer of DHMS, told Personal Finance that often, particularly in the case of emergencies not treated in hospital, the information that the scheme initially receives is limited to the ICD-10 (diagnostic) and tariff codes on the claim.

“This information alone is not sufficient to establish a reliable PMB diagnosis, and the scheme therefore requires additional clinical information or confirmatory evidence to determine whether the circumstances of the case meet the definition of an emergency.”

He said Discovery Health’s clinicians reviewed the decision and agreed to pay Du Toit’s accounts in line with the PMB code of conduct after they had received a letter of motivation from the head of the emergency room and considered the circumstances of the case.

The administrator may pay for diagnostic tests performed while it is assumed that a condition is an emergency. The decision depends on the clinical nature of the case, and the urgency and suitability of the investigations and treatment required, Streak said.