Responding, Discovery Health told the ARB the Medical Schemes Act and its regulations required medical schemes to cover costs related to the diagnosis, treatment and care of a defined list of 27 chronic conditions, according to the prescribed minimum benefits (PMBs).
The scheme said it provided comprehensive chronic cover, under its chronic illness benefit (CIB), for the 27 chronic conditions listed in the Act plus an additional 22 chronic conditions.
“Once enrolled for the CIB, Discovery Health members received cover for approved medicine for the 27 PMB chronic disease list (CDL) conditions on all plans, with approved medicine on the CIB medicine list (formulary) funded up to the scheme rate at a network pharmacy.
“The CIB also covers a specific number of tests, procedures and consultations for the diagnosis and ongoing management of the CDL conditions to ensure a holistic and comprehensive healthcare approach is taken.”
Medication cover was subject to the chronic drug amount (CDA), “the monthly amount the scheme will pay for a medicine class, subject to a member’s plan type, for chronic medicine not listed on the medicine list (formulary)”, Discovery said.
“Approved medicine for Smart and Keycare members not on the medicine list will be funded up to the therapeutic reference price for the equivalent medicine or group of medicines.”
The scheme provided cover “for the treatment and ongoing management” of asthma, haemophilia, hypertension, hypothyroidism and major depression, it said.
“Alzheimer’s and dementia are not classified as PMB conditions and do not form part of the chronic disease list or the additional disease list. While cover for these conditions is not provided by the scheme’s risk benefits, a member is able to fund treatment for these conditions from their medical savings account, subject to funds being available.”
The word “comprehensive” was meant to describe the benefits offered once patients qualify for chronic cover and is not intended to indicate most chronic conditions are covered, Discovery said.
Pattison said in his experience there were three hurdles for a member on chronic medication to overcome to be fully covered.
“First, your condition needs to be a prescribed minimum benefit on the chronic disease list.
“Second, your medicine needs to be on the chronic illness medicines list (CIML). It would seem the CIML includes only the drugs for serious versions of the chronic condition.
“Third, you have to have specific tests. That your doctor has prescribed the medicines and you take them is not sufficient.
“The net effect is many of the most commonly prescribed medications for hypertension, depression, thyroid conditions, arthritis, and so on are not covered. And you only find this out once you apply.”
Mother's health spurs businessman Grant Pattison to take on Discovery Health for advertising claim
Consumer journalist
Image: Freddy Mavunda
Discovery Health has been ordered to qualify its claim to offer “comprehensive” chronic cover after being called out by a prominent South African businessman.
Grant Pattison, whose positions have included CEO of Massmart Holdings and Edcon, lodged a complaint with the Advertising Regulatory Board (ARB) with respect to an advert for “comprehensive chronic cover” the medical scheme posted on X (Twitter) early last month.
The advert was misleading, Pattison said, because Discovery Health did not provide cover for all chronic diseases and excluded cover for treatment of some of the most common chronic conditions, including depression, dementia, asthma, chronic anaemia and hypertension.
The word “comprehensive” was used to make people think they cover most chronic conditions, Pattison said, “which, by their own admission, they don't”.
He took up the cause on behalf of his elderly mother who takes several chronic medications, “none of which were covered by Discovery's 'comprehensive chronic cover' product,” he said.
Responding, Discovery Health told the ARB the Medical Schemes Act and its regulations required medical schemes to cover costs related to the diagnosis, treatment and care of a defined list of 27 chronic conditions, according to the prescribed minimum benefits (PMBs).
The scheme said it provided comprehensive chronic cover, under its chronic illness benefit (CIB), for the 27 chronic conditions listed in the Act plus an additional 22 chronic conditions.
“Once enrolled for the CIB, Discovery Health members received cover for approved medicine for the 27 PMB chronic disease list (CDL) conditions on all plans, with approved medicine on the CIB medicine list (formulary) funded up to the scheme rate at a network pharmacy.
“The CIB also covers a specific number of tests, procedures and consultations for the diagnosis and ongoing management of the CDL conditions to ensure a holistic and comprehensive healthcare approach is taken.”
Medication cover was subject to the chronic drug amount (CDA), “the monthly amount the scheme will pay for a medicine class, subject to a member’s plan type, for chronic medicine not listed on the medicine list (formulary)”, Discovery said.
“Approved medicine for Smart and Keycare members not on the medicine list will be funded up to the therapeutic reference price for the equivalent medicine or group of medicines.”
The scheme provided cover “for the treatment and ongoing management” of asthma, haemophilia, hypertension, hypothyroidism and major depression, it said.
“Alzheimer’s and dementia are not classified as PMB conditions and do not form part of the chronic disease list or the additional disease list. While cover for these conditions is not provided by the scheme’s risk benefits, a member is able to fund treatment for these conditions from their medical savings account, subject to funds being available.”
The word “comprehensive” was meant to describe the benefits offered once patients qualify for chronic cover and is not intended to indicate most chronic conditions are covered, Discovery said.
Pattison said in his experience there were three hurdles for a member on chronic medication to overcome to be fully covered.
“First, your condition needs to be a prescribed minimum benefit on the chronic disease list.
“Second, your medicine needs to be on the chronic illness medicines list (CIML). It would seem the CIML includes only the drugs for serious versions of the chronic condition.
“Third, you have to have specific tests. That your doctor has prescribed the medicines and you take them is not sufficient.
“The net effect is many of the most commonly prescribed medications for hypertension, depression, thyroid conditions, arthritis, and so on are not covered. And you only find this out once you apply.”
In its finding, the directorate relied on the definition of “comprehensive” as “including everything that is necessary; complete”.
But to receive cover for more than the 27 PMB illnesses, the member needed to be on a specialised or “higher” package, the directorate said.
“It seems the advertiser claims to provide 'comprehensive chronic cover' because it covers those medicines every medical aid is obliged by law to cover.
“The directorate believes the advertising implies the advertiser offers something over and above the legal minimum PMB benefits.
“But from its submission, this does not appear to be the case.
“It seems what is offered is 'comprehensive PMB cover', which it is legally obliged to offer, [hence] the advertising is misleading”.
Discovery Health was instructed to amend the advertising to qualify the claim “comprehensive chronic cover”.
TimesLIVE
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