Medical schemes must pay for Covid tests? Not always, they claim

Picture: 123RF/MICROGEN
Picture: 123RF/MICROGEN

Last week, a Durban North woman sat down to document what she believed to be a major injustice to her 73-year-old husband, a cancer patient who is undergoing regular chemotherapy sessions.

She then e-mailed her story to me, and I’m so glad she did, because it set in motion a chain events that could benefit many others.

I’ll call the couple Keith and Shirley, to protect their privacy. They have both been members of Momentum Health, previously Natal Medical Plan, for more than 40 years, and hadn’t claimed much, until Keith was diagnosed with a form of cancer about four years ago.

Last year his condition worsened, and from September his once-monthly chemo sessions became weekly, all of them covered by the medical scheme under its cancer benefit.

The medical service providers required Keith to have a Covid-19 test before each session, which, at a cost of R850 a time, would amount to about R15,000 over the six-month course, which Momentum refused to pay out of their fund.

“If he does not have Covid clearance, he cannot enter the cancer treatment ward to have his chemo, as he cannot endanger the lives of others who are also having treatment,” Shirley told me.

But still it was “tough luck” from Momentum, Shirley said, despite a letter from Keith’s haematologist arguing that the Covid tests should be covered under the scheme’s cancer code.

In Momentum’s initial response, executive Damian McHugh said while Covid testing was covered by the scheme, “we need to follow due process in protecting members’ funds, and we apply industry standard practices in this regard”.

“As the health-care industry puts in place the processes to adequately and sustainably assist South Africans in overcoming this global pandemic, there will be instances like this where we come across a process that needs to be revisited and refined.”

Then came a hint as to the crux of the issue: “The results of a Covid-19 test conducted weekly would not be accurate as the test is done almost every five days.

“We would not want patients to feel discouraged from going to the hospital for important treatment, such as chemotherapy. We simply need to ensure that unnecessary testing does not erode the funds we need to cover testing, treatment and vaccines going forward.”

The upshot, though, was good news for Keith and Shirley: “We have further taken the decision to cover the cost of the tests done to date from Risk for this member.”

Chatting to McHugh later, a fuller story emerged. The scheme is of the view that requiring Keith to get a Covid test before every one of his weekly chemo sessions was not scientifically warranted, and a waste of members’ funds.

“It’s an industry-wide debate and our member got caught up in it, but it’s not his problem,” McHugh said. “His energy and that of his wife should be going into fighting cancer.

“Over-testing is a problem; this is a new situation and we are all trying to find a balance, but we did not handle this matter as well as we should have.”

So the R7,400 which was taken from Keith’s medical savings account to cover his Covid tests in the past months has now been put back. And Shirley tells me the medical scheme has told her that it is currently engaging with the hospital and Keith’s doctor’s rooms about the weekly Covid tests they’ve been requiring Keith to have.

But they’ve reminded the couple that: “Routine pre-screening/pre-admission Covid testing for asymptomatic patients which turns out negative is not prescribed minimum benefit (PMB) level of care and is not paid for by the scheme and will be subject to member’s day-to-day benefit.

“This is in line with Council for Medical Scheme’s guideline for Covid-19 ...”

Something seems very off about that guideline to me when it comes to this particular scenario. As Shirley said to me in that first e-mail: “If my husband did not have cancer, and did not need weekly chemo, he would not need weekly Covid testing. It has been a compulsory part of his cancer treatment, so therefore should be covered under his cancer benefit.”

You’d think ...

To be continued, for sure.

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