A Mitchells Plain couple have emerged victorious after an extremely exhausting and challenging battle with Discovery Health.
The Barons took on the medical aid provider after it refused to pay for chronic medication.
Lucretia Baron was diagnosed with breast cancer in June last year. She had chemotherapy and subsequently a bilateral mastectomy in December.
Doctors discovered she’d developed a pulmonary embolism. They prescribed medication called Clexane. Her husband Brian went to Clicks to get it. On the first few occasions the amount was deducted from his medical savings. But two top-ups that followed were declined and he was forced to pay for the medication from his own pocket.
Brian was furious. An IT and telecommunications technical lead for over 23 years, he decided to don the hat of mediator and lawyer in this David versus Goliath battle.
When Lucretia, 43, was first diagnosed, the family was overwhelmed.
She told Weekend Argus: “I was feeling despondent, frustrated and uncertain while I was fighting breast cancer.”
Brian said: “During this time I had to support my wife through her cancer journey, function at 110% in my job, and support our two boys by educating them on my wife’s situation.”
The Barons decided to treat the cancer through chemotherapy, a process that lasted five months. Lucretia had surgery on December 4 and doctors noticed an unusually high heart rate. Tests showed she’d developed blood clots in her lungs. She was treated with Clexane, a pricey blood thinner and monitored overnight.
“On 6 December, the medical team was still not happy with her heart rate and decided to do a cardioversion on her to get her heart rate stable,” explained Brian. "The cardioversion was successful and her heart was restored back to normal."
Lucretia was discharged from hospital on December 11.
Her physician provided her with a prescription for one month’s supply of Clexane. “We went to the pharmacy to purchase the Clexane, we discovered that it cost nearly R9 000,” said Brian.
“We asked the pharmacist what alternatives there were, and we were advised to buy it in batches of 10. We did it through our medical aid savings, which would last for five days. The physician then submitted a prescribed minimum benefit (PMB) application to the medical scheme. Discovery advised that this process could take up to 20 business days.”
The Barons restocked their Clexane supply on December 17, 21 and 25 through their medical savings. But on December 30 their purchase was rejected.
Brian said a Discovery Health advisor told him the system blocked the transaction due to the medication being purchased too many times within a 23-day window.
“I explained to the Discovery representative on the phone, that the full months’ supply was not issued. The representative was not willing to assist. She advised that I should purchase it from my personal funds. I told her I do not have that kind of money. She replied ’well then your wife will remain without treatment until 12 March 2021’. No sympathy from her,” recalled Brian.
“I decided to pay for the medication myself. It cost R1 470. Later that day I received an email from the medical scheme saying my PMB application was declined. Their clinical board suggested a cheaper medication, Warfarin. But Clexane was the preferred treatment for cancer patients from the team of specialists.”
A quick search of medical journals on the internet revealed that Clexane is a lot more advantageous than Warfarin, mainly because it leaves the body faster.
Another Clexane refill on January 4 was declined. Again Brian had to fork out cash.
He submitted his claims to get the money back - a total of R3 184.92 but Discovery was having none of it.
Brian logged a dispute and spent months to-ing and fro-ing with Discovery, whose complaints department ruled against him.
Dissatisfied, Brian approached a lawyer who said it’s going to cost him more in legal fees than what he was owed.
So he decided to tackle Discovery head-on himself and approached the Council of Medical Schemes. “I did a lot of research. I spent a lot of time reading up on the acts, like the Medical Aids Act and the Schemes Act to prepare for the hearings.
Brian won.
Discovery paid his money back this week. “It’s been tough fighting these people. Because as a member you expect them to help you through the process and pay the benefits due to the member. They bullied and insulted me. But the Council for Medical Schemes was actually quite efficient and overturned Discovery’s ruling. They said the purchases or claims should have gone off the risk benefit and the chronic illness benefit.”
Lucretia said: “Ideally I would like my medications to be approved, especially if prescribed by a specialist physician. No hassles, no fussing, no back and forth.”
Discovery responded: “Following the CMS ruling, all Clexane claims have been settled by the scheme in full and from the scheme benefits. In addition, Mr Baron’s MSA has been credited and all refunds made for the cash payments made to the pharmacy.”
Discovery added: “We deeply regret that Mr Baron felt bullied through the process and apologise for the unfortunate experience. The process is designed to allow members of the scheme the opportunity to fairly present their case and be provided with detailed information relating to the scheme’s funding rules and protocols with the main aim of coming to an amicable resolution of the dispute.”
The Barons’ fight for a little over R3 000 may seem insignificant to some, but think of it this way - if a thousand individuals decided to take on big corporates like Brian and Lucretia did, that’s R3 million.
Lucretia's advice to other members is: "Do not give up, as you are paying for a service. They should provide what you pay for."
Weekend Argus