CMS ruling: Patients could demand medical aids pay for treatments

A ruling by the Council for Medical Schemes (CMS) opens up the potential for members to demand that their medical aid pays for any drug or medical care deemed necessary by a doctor to treat any disease that falls under PMB basket of care.

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This is after a glaucoma patient took on Discovery Health Medical Scheme because it refused to pay for a medicated device called a Xen stent to lower eye pressure as recommended by a specialist, even though it was willing to pay twice as much as the device costs for treatment it recognises. The medical scheme denied the claim on the basis that clinical evidence around the implant was weak. It also said it was legally entitled to refuse payment for the device because it was not available in state hospitals.

The ruling could have a huge impact for cancer patients, where, in the past medical aids have refused to pay for drugs outside of their formulary. Last year, Dr Sipho Bvuma asked his medical scheme Gems, to pay for a special drug treatment called Keytruda for his stage 4 brains cancer. At first, Gems refused because the medication is not registered in South Africa as a treatment option for the specific type of cancer. It was only after Bvuma instituted court proceedings that the scheme changed its mind.