Sunday Times

Regulator ‘contradict­s itself’ over health bills

- 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 semiparaly­sed, 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.

 ??  ?? Moira Rodinis
Moira Rodinis

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