Regulator 'contradicts itself' over health bills

26 May 2019 - 00:00 By KATHARINE CHILD

Moira Rodinis, 85, is going blind. Within her reach is a drug called Eylea, that will reduce fluid build-up in her eyes, caused by age-related macular degeneration.
But trying to get her medical aid to pay for the treatment has put her in a race against time. In March, she won a long fight for Discovery Health to pay the full cost of her treatment after appealing to the regulator - but then it was back to square one as the medical aid appealed the outcome of her appeal.
At the heart of Rodinis's battle is seemingly a change in practice at the regulator. Rodinis's legal consultant and industry experts say that previously the Council for Medical Schemes (CMS) would enforce appeal decisions, even if a second appeal was under way. This means she would have received her treatment while the second appeal process was pending.
However, this is no longer the case, with CMS spokesperson Grace Khoza saying the council could not enforce rulings if a second appeal had been lodged, in the same way courts do not enforce decisions when there is an appeal to a higher court.
Her comment contradicts registrar Sipho Kabane, who has said under oath in legal documents that the council's interpretation of the Medical Schemes Act is that the decisions of its appeal board must be enforced, even in the face of a new appeal. Khoza did not respond to requests to explain the contradiction.
In Durban, 74-year-old Storm Ferguson is in a similar position. Ferguson, who is semi-paralysed, has been locked in battle with Discovery since 2015.
He wants them to pay for doctor-recommended catheters instead of reusable ones, which he says cause recurring infections.
He won his case before the council appeal committee on March 13, but the ruling has not been enforced because Discovery is appealing against the council's decision.
His consultant, Elsabe Klinck, who is handling four similar cases including one with Gems medical aid, said they could not find out why the council had, "after close to two decades", now changed its view.
She also said the court cases the council cited to defend its decision not to enforce appeals were not relevant, as the appeals process was not a court process but governed by the Medical Schemes Act.
Rodinis's son, Anthony, first took the matter to Discovery in an internal appeal process in 2017. Discovery has recently agreed to pay some of the costs of her injections, but Rodinis wants the full cost covered, as ordered by the council's appeals committee in March.
Wits professor and economist Alex van den Heever, who used to work for the regulator, speculated that either the registrar had lied under oath, or the CMS has changed its interpretation of the law to favour industry.
"It appears they alter their interpretation of the law depending on which side of an issue large industry players sit. No competent authority acting with integrity would conduct itself in this way. The arbitrary nature of the decisions plainly exposes the CMS to legal action."
Discovery Medical Aid principal officer Nosipho Sangweni said it had agreed to fund both Ferguson's and Rodinis's treatments in part, while pursuing its legal rights to have decisions reviewed by the appeal board.
Gems said its legal advice was that no action would be taken until the outcome of a final appeal...

There’s never been a more important time to support independent media.

From World War 1 to present-day cosmopolitan South Africa and beyond, the Sunday Times has been a pillar in covering the stories that matter to you.

For just R80 you can become a premium member (digital access) and support a publication that has played an important political and social role in South Africa for over a century of Sundays. You can cancel anytime.

Already subscribed? Sign in below.



Questions or problems? Email helpdesk@timeslive.co.za or call 0860 52 52 00.

Would you like to comment on this article?
Sign up (it's quick and free) or sign in now.

Speech Bubbles

Please read our Comment Policy before commenting.