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Whilst the member primarily drives the challenge of a negative decision by a medical scheme to a particular claim by a member, the member may usefully receive support from medical professionals and healthcare providers for purposes of motivating why the claim should be allowed.
Benefits may be denied for a number of reasons: benefits may be exhausted; the particular treatment or medicine may not form part of the medical scheme’s protocols or formularies, respectively, or the medicine proposed by a medical practitioner may not be registered as a medicine in terms of South African legislation and unavailable to patients as a registered medicine.
When a member’s claim for assistance from a medical scheme is denied, there are a number of courses of action available to a member in order to challenge the negative decision by the member’s medical scheme.
Medical practitioner’s motivation is especially pertinent in circumstances where claims, based on unregistered medicines or medicines not available in South Africa but readily in use in other jurisdictions, are the reason for the medical scheme’s negative decision. Medical practitioners are ideally placed to explain to funders why particular medicines are needed by the patient over and above others and the effects of both the use of the medicine by the member on the member’s health and, in circumstances where the claim is denied, the health effects of the unavailability of the medicine to the member. Such motivations are commonly required in dealing with claims based on members with rare cancers and where medicines are uniquely available in particular jurisdictions but not in South Africa.
The particular role to be played by a medical practitioner or healthcare provider in a process of complaining about a medical scheme’s negative decision by a member would typically amount to the following:
Ideally, disputes with medical schemes should be avoided in the interests of achieving the best possible care and outcome for the member/patient. Therefore medical practitioners and healthcare providers should take care in providing advice in respect of certain treatment regimens that are financially unavailable to a member based on his or her medical scheme benefits. Alternatively, they may advise that certain treatment regimens are available to a member but may not be supported by the member’s medical scheme but that notwithstanding the medical practitioner will support the member in achieving a possible payment by a medical scheme with the requisite support and written and, if needs be, oral motivation/s.
It does not make any sense for a member/patient to be advised of a particular treatment regimen, which his or her medical scheme will not support based on its rules. Then, when faced with a negative decision, the medical practitioner or healthcare provider is simply unavailable to the member to motivate why such a treatment regimen or medicine was prescribed as being in the best interests of the member. Both funding and medical decisions should be made responsibly vis-Ă -vis member and his or her health and best interests.
This principle is recognised in the MSA in the context of Regulation 8 of the General Regulations promulgated in terms of the MSA, which deals with prescribed minimum benefits. Regulation 8(3) deals with the exemptions to the imposition of the general principle of a member receiving treatment from a designated service provider:
“For the purposes of sub-regulation (2)(b), beneficiary will be deemed to have involuntarily obtained a service from a provider other than a designated service provider, if:
The words emphasised in the abovementioned quotation indicate an objective criteria being applied to what is or is not reasonable. Part of the criteria would arguably be a report from a medical practitioner or healthcare provider dealing with matters of what is or is not reasonable vis-Ă -vis the member/patient.
In addition to the particular provisions of the MSA, when dealing with advice provided to patients, medical practitioners and healthcare providers are reminded of their obligations in respect of achieving informed consent, which includes dealing with matters of cost. This is in terms of Chapter 2 of the National Health Act, the ethical obligations under the Ethical Rules published by the Health Professions Council of South Africa in 2006 in the Government Gazette and Booklet 9 published by the Health Professions Council of South Africa in May 2008 entitled ‘Seeking Patients’ Informed Consent: the Ethical Considerations’.