Check cancer cover on medical aid before cut-off date

Every year many medical aid members over-look those 'unnecessary' emails or printed documents asking them to review their current plan and medical cover. However, with the burden of cancer being so high and cancer treatments often being costly, medical aid members and cancer patients cannot afford to be complacent about the medical aid plan they purchase.

The major medical schemes offer their members the opportunity to review their plan for a short period (9-30 December 2011). Post these dates, upgrading in order to receive better cover for cancer treatments is not possible again until December 2012.

South Africans may make decisions on medical cover without knowing what that cover actually entails. Members often do not consider what the costs of cancer treatments are, how much cover is afforded, what the terms such as 'exclusions' and 'biological therapies' mean and how they affect medical cover.

"Campaigning for Cancer regularly gets calls from cancer patients whose medical aids won't pay for their treatments. We realized that this is becoming a big concern and want to encourage more patients and their families to share their experiences so we can get a clearer understanding of how we can educate and equip medical aid members better in their decisions about cancer cover," says Campaigning for Cancer CEO, Lauren Pretorius.

"Cancer patients who would like to share their medical aid experiences can do so on the Campaigning for Cancer mini website, which focuses on cancer medical aid cover," she added.

Jeannick Langeveld, who has been advocating on a number of occasions for her husband's lung cancer treatment, says, "What patients and their families need to realize, is that there are exclusions for some treatments. If we had known this prior to my husband's cancer diagnosis, we could have put other options in place like gap cover or dreaded disease cover."

Although there are various options available, a decent oncology benefit could consist of an overall annual limit of about R300 000 to R400 000 per beneficiary.

What members should know

Members should be aware of benefits that promise 'Unlimited Cover', as this often is not the case. Often the scheme rules exclude many of the newer innovative treatments, which tend to be more costly than standard chemotherapy, despite the fact that the Medicines Control Council (MCC) has approved them.

Some scheme's lower benefit options offer between R 90 000 or R150 000 cancer cover per family. With this amount of cancer cover, members will only be provided with treatment in line with prescribed minimum benefits (PMBs), which are equal to what you would have received if you went to a government hospital for your cancer treatment or care.

The cost of medicines used in oncology is often the main problem members' face when trying to get medical schemes to cover the treatment plan recommended by their doctor. Many scheme's rule even state that newer cancer medicines are excluded on certain plans. As a result, members have to pay for these medicines out of pocket. These newer medicines, often referred to as specialized medicines or biologics, do not have a generic alternative and some of them can cost anything between R100 000 to R500 000.

Members should also be clear about payment for consultations to oncologists or other specialists and check whether their scheme limits the number of visits to a specialist and how much is allocated for specialist consultations.

Terms must be understood

Campaigning for Cancer suggests cancer patients should also insist on knowing if the scheme's decisions about their treatment are made by oncologists and not by professionals who may not necessarily have the required expertise in oncology. This is because in some cases schemes appoint a managed care company to manage their protocols and determine if patient's treatment is in line with the set protocols.

According to Section 41(1) (a) of the Medical Schemes Act No. 131 of 1998, medical aid members are entitled to ask to see their scheme's treatment protocols, rules and exclusions and, according to the Consumer Protection Act, they have a right for all these things to be provided in a language and manner they understand. "Don't be afraid to ask for clarification if you do not understand what is being said. Keep asking until you do understand," adds Pretorius

The scheme rules, protocols and formularies differ between the benefit options on a specific scheme and from scheme to scheme. Campaigning for Cancer says members should get all the information they need to make an informed choice before signing on the dotted line.

"People often take the easy route out by just continuing with their current medical aid plan and sometimes even opt to reduce cover in order to save an extra couple of Rands. " Medical cover has become a necessity in our modern environment, the burden of cancer is high and we want people to look more closely at whether they can afford not to be appropriately covered for a cancer diagnosis and treatment.

"With many of the larger schemes allowing you to upgrade and downgrade at this time of the year, we urge you to assess your 2012 cancer benefits now. It's advisable for members to query the cut-off dates it with their scheme directly," concludes Pretorius.