Is it fair to expect members to figure out how prescribed minimum benefits work?

There is little benefit in having prescribed minimum benefits (PMBs) if medical scheme members are not aware of them and no one has a duty to inform them of their entitlement.

Heavyweight legal teams may be debating the issues associated with the PMBs that go to the heart of private healthcare funding, but members are still struggling to enjoy the protection the legislation was intended to provide, the recent struggles of a medical scheme member show.

Mrs D, who found out through her own dogged research that her son’s and her husband’s conditions are PMBs, is now questioning whose responsibility it is to inform you of your rights to PMB cover.

The answer she has found is that it is up to you to be informed.

Mrs D’s teenage son was diagnosed with a major depressive disorder in March 2014.

In September, he suffered a breakdown, and a psychiatrist who treated him admitted him to a clinic, where he spent what Mrs D says was a terrifying night in a room with a gang member and had group therapy with people with drug addictions and behavioural problems.

The teenager was then referred to a psychologist and has been progressing well as a result of therapy, Mrs D says.

She discovered that her son’s condition is a PMB, covered as “major affective (mood) disorder”, and that the benefits entitled her son to be admitted to a facility for up to three weeks or to 15 sessions of psychotherapy, or a combination of the two.

Mrs D, who had paid for all her son’s treatment, claimed for her son’s treatment as a PMB from her medical scheme, Discovery Health. All the claims were then paid out.

Mrs D attempted to lay a complaint with the Health Professions Council of South Africa (HPCSA) against the psychiatrist who failed to inform her and her son of the treatment options under the PMBs.

Dr Munyadziwa Kwinda, the Ombudsman for the HPCSA, however, informed Mrs D that she had no basis to pursue a complaint against the psychiatrist, because she, as a member, is responsible for knowing what her medical scheme covers and does not cover. Kwinda told Mrs D that her doctor has no relationship with her scheme, only she does.

Mrs D also contacted the Council for Medical Schemes, but she has been advised that she does not have grounds for a complaint.

In addition to the problems Mrs D had with her son’s condition, she found herself having to be alert when her husband, a diabetic, was treated for hyponatremia, a potentially lifethreatening condition and a PMB.

The treatment he received in hospital was covered, but the consultations and tests that led to his diagnosis were not covered in full as PMBs until Mrs D queried this with Discovery Health. There was also a dispute over whether her husband’s treatment was an emergency or he should have sought treatment with the scheme’s designated service provider.

Elsabe Conradie, the general manager for stakeholder relations at the Council for Medical Schemes, says healthcare providers are legally and ethically obliged to discuss with you all the treatment options available to you.

She says they ought to formulate your treatment options based purely on their clinical judgment, without being influenced by the funding you may enjoy for a PMB condition.

Conradie says there is no legislation that obliges a provider to alert a member that a condition is a PMB. However, providers are encouraged to familiarise themselves with the PMBs and to alert their patients to these conditions.

The Council for Medical Schemes also encourages providers to understand the PMBs, so that they do not inadvertently give you unrealistic expectations of your funding entitlements, Conradie says.

She says it is your responsibility to discuss the treatment options with your scheme, and your scheme is, in turn, obliged to discuss your PMB entitlements with you, but only after you have been diagnosed. In this way, you are empowered to make an informed decision after accessing the best unbiased medical advice.

Conradie says if the responsibility for informing you about the PMBs lay solely with doctors and other healthcare providers, providers could find themselves in an ethical quagmire, because they would have to decide whether a particular treatment was in your interests medically or financially. They may also be conflicted in deciding whether a treatment is best for you or provides them with the most reimbursement from a scheme.

Conradie says the fact that you belong to a scheme creates a thirdparty payer arrangement, which should not add to the legal responsibility of providers. However, she admits, these arrangements put an additional burden on members, who have to interrogate not only the clinical jargon, but also the sometimes complex funding permutations in their schemes’ rules.

The Council for Medical Schemes also pointed out that major depression is not included as a chronic condition on the list of chronic diseases covered as PMBs. It says this means that ongoing out-of-hospital medication and pathology for the condition may not be paid as a PMB, because benefits are limited to out-of-hospital psychotherapy. However, a scheme may offer cover for medication according to their rules and medical protocols, the council says.

Mrs D says the PMBs are a great piece of legislation, but it is difficult to know whether your condition is a PMB, and the list of PMBs is difficult to follow.

She says that, if she had not trawled the internet, she would never have known that her son’s condition was, in fact, covered by the PMBs.

I couldn’t agree more with Mrs D. Even as a relatively informed writer on medical scheme issues, I have found it difficult to navigate the PMBs. I am sure many consumers are either unaware of the benefits to which they are entitled or give up after a medical scheme refuses to acknowledge that a claim is covered by the PMBs.

Although some schemes have made an effort to publish the PMBs and to alert their members to their rights, much more can be done, particularly if schemes want to pass the test of Treating Customers Fairly (TCF).

Small wonder many others don’t, however, as schemes have to balance their books – your collective contributions against your collective claims – while being exposed to an open-ended liability for PMBs.

The TCF principles will guide the regulation of all financial products in future. One of the six aims of TCF is that customers are provided with clear information and kept appropriately informed before, during and after the point of sale.

Can you really describe as “clear information” the republication of the list of clinical conditions and their related ICD10 codes, as they appear in the regulations, and that are largely incomprehensible to ordinary mortals?

Although there may be merit in the argument that there should not be a conflict between doctors’ treatment recommendations and the benefits to which you are entitled, the reality is that doctors often have conversations with patients about the treatment they can afford. It is not helpful if, in the course of that conversation, you ask a doctor if a condition is a PMB and the response is “What is a PMB?”.