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

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.