Medical aid allowed to cap cancer drug benefit

08 October 2015 - 02:19 By Katharine Child

Bonitas Medical Scheme does not have to pay for a year's supply of the breast cancer drug Herceptin for one of its members. The final-appeal committee of the Council for Medical Schemes has ruled in favour of Bonitas, saying the plan chosen by the claimant, Veroney Judd-Stevens, of Pietermaritzburg, did not cover her for a year's supply of the drug.The appeal panel, led by Judge Bernard Ngoepe, said "in light of the scheme's rules, the specialised drug limit was R200,000. The rules were registered with the Council for Medical Schemes and therefore served as a contract between Judd-Stevens and Bonitas".Bonitas and several other medical aids cover Herceptin for nine weeks, despite a year being the international standard for treatment with the drug.Judd-Stevens was prescribed the drug for a year to prevent the return of an aggressive form of HER2-positive breast cancer.Herceptin, which costs at least R500,000 for a year's course, reduces the risk of the cancer returning by 40%.Judd-Stevens had cover for only 17 weeks of treatment.Bonitas agreed in legal papers that the drug should be used for a year but said that that was not affordable or legally necessary. About a month ago the scheme decided - on a once-off ex gratia basis - to cover her treatment for a year.Judd-Stevens said she had taken up the fight to ensure that other cancer sufferers were able to access a year's treatment.Bonitas principal officer Bobby Ramasia said: "As matters currently stand, this ruling is indicative of Bonitas's legal obligations to provide Herceptin."The scheme said it was was reviewing the evidence and would consider for how long Herceptin should be made available to its members...

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