New Discovery limits irk members

Discovery Health is clamping down on abuse of its medical scheme but has angered some members and health professionals, who fear a reduction in benefits.

The South African Depression and Anxiety Group said this week that, despite an increase in premiums of 8.9% next year, Discovery Health Medical Scheme members will have limits placed on mental health benefits.

But Discovery Health CEO Jonathan Broomberg said several cost drivers were significantly above inflation for medical schemes. Private hospital costs outstrip inflation by more than 3%; the prices of new drugs for chronic conditions are rising at over 30% a year, and treatments for chronic conditions are also more expensive.

Discovery Health Medical Scheme, the largest medical scheme administrator, has put 15 therapies into a single category of "allied health benefits", placing limits on how much the scheme will pay once members have used up their medical savings accounts.

The affected therapies include psychologists, homeopaths, chiropractors and dieticians.

Previously, members were covered automatically once through their self-payment gap. From January, this will no longer be the case.

In terms of the new benefit, these therapies will be covered up to R19000 per family. The scheme has put in place an "extender benefit" which will provide unlimited cover to members suffering from serious conditions which require unlimited cover. Discovery may extend the list of conditions which qualify for unlimited cover.

Discovery said the new limit would affect less than 5% of those who claim for allied health benefits on the top three plans - equivalent to about 7000 people out of the scheme's total of 2.3million. Broomberg said many of these would qualify for unlimited benefits under the "extender benefit".

Broomberg said cases such as bipolar disorder fell under a prescribed minimum benefit and would still be covered from the scheme's risk pool. The same applies to other serious mental health and clinical conditions.

"It's aimed at being flexible and should cut down on the worst abuse, while still ensuring that those families with real need are covered in full."

Broomberg said the proportion of premiums spent on non-health-care items was just above 11% at Discovery Health. "Four years ago it was above 14% of premiums, and the aim is to get to 10%."

Peter Edwards, MD of Alexander Forbes Health, said any reduction in benefits was negative. "With the high stress rate, rate of unemployment and high debt, people need support," he said.

Andre Jacobs, head of operations at AonHewitt, said while some people would be worse off others would be better off under the new regulations. If only one person used the set of benefits they would be capped, while those with family members were likely to have more cover available.

Clayton Samsodien, MD of Genesis Healthcare Consultants, said members would have to pay more and service providers in those categories would suffer.

Psychiatrist Dora Wynchank said the change was "one of the ways psychiatric patients or people with emotional problems are discriminated against. Many common psychiatric illnesses like depression are not considered prescribed minimum benefits. But 20% of women and up to 12% of men suffer from depression. It's very disabling and it's genetic."

Another problem was that educational psychologists would not be covered under the new benefit structure, said Wynchank.