What you can ex­pect your med­i­cal scheme to cover for stage zero can­cer

Weekend Argus (Saturday Edition) - - GOODPOSTER -

You can’t bank on pre­scribed min­i­mum ben­e­fits (PMBs) to en­sure that your med­i­cal scheme will cover your treat­ment for pre-ma­lig­nant can­cer or pre-can­cer­ous cells.

But if you be­long to a med­i­cal scheme op­tion with a high level of ben­e­fits, your treat­ment may well be cov­ered, al­beit to a vari­able ex­tent, by your hos­pi­tal ben­e­fits.

David Eedes, a clin­i­cal ex­ec­u­tive for Icon, an in­de­pen­dent clin­i­cal on­col­ogy net­work, says that in many cases of stage zero (pre-ma­lig­nant) can­cer, you are not en­ti­tled to the cover that the PMBs pro­vide for can­cer, be­cause, in or­der for the dis­ease to be clas­si­fied as can­cer, the cells have to be in­va­sive, rather than pre-ma­lig­nant, as they are in stage zero can­cer.

If you re­quire surgery for stage zero breast can­cer or a cone biopsy for stage zero can­cer of the cervix, your med­i­cal scheme should cover your in­hos­pi­tal treat­ment, but your doc­tor and anaes­thetist may charge a higher rate

You should buy the best med­i­cal cover you can af­ford, and con­sider top­ping up cover that has lim­its with, for ex­am­ple, a gap cover in­sur­ance pol­icy, Eedes says.

How­ever, he warns that gap cover poli­cies can have strict con­di­tions that can re­sult in ben­e­fits be­ing de­nied, be­cause your ill­ness does not meet all the re­quire­ments that would qual­ify you for a pay­out.

Peter Jor­dan, prin­ci­pal of­fi­cer of Fedhealth, says al­though Fedhealth’s on­col­ogy ben­e­fit may not cover your treat­ment for stage zero can­cer, each case is as­sessed on its mer­its and the cover will vary de­pend­ing on your needs and the med­i­cal scheme’s man­aged care pro­to­cols.

Fedhealth cov­ers di­ag­nos­tic tests, such as blood tests or mam­mo­grams, from its pathol­ogy or well­ness ben­e­fits, while biop­sies (re­moval of tis­sue to de­ter­mine the pres­ence or ex­tent of a dis­ease) are cov­ered from the hos­pi­tal ben­e­fit in line with the scheme’s clin­i­cal guide­lines, rules and ben­e­fit lim­its.

Fedhealth al­lows its mem­bers to buy up to a higher op­tion when they are di­ag­nosed with a life-chang­ing con­di­tion, so they can ac­cess treat­ment that is ap­pro­pri­ate to their needs, Jor­dan says.

How­ever, most med­i­cal schemes do not al­low you to move to a higher op­tion dur­ing the year, only at the be­gin­ning of each year.

Alain Ped­dle, head of re­search and de­vel­op­ment at Dis­cov­ery Health, says if you are a mem­ber of a med­i­cal scheme ad­min­is­tered by Dis­cov­ery and you have his­to­log­i­cal (mi­cro­scopic study of tis­sue) con­fir­ma­tion of a ma­lig­nancy, rather than a par­tic­u­lar stage of can­cer, you can reg­is­ter for the on­col­ogy ben­e­fit, which will give you ac­cess to the ben­e­fits pro­vided by your cho­sen op­tion.

If the can­cer re­quires sur­gi­cal man­age­ment, the hos­pi­tal ben­e­fits will ap­ply ac­cord­ing to your op­tion and the scheme’s rules.

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