[LISTEN] Discovery explains why it's unable to cover treatment for Sim twins
Last week Joanne Joseph spoke to Loren Sim whose twins have an autoimmune condition that makes it impossible for them to eat normal food and are fed Neocate, a formula, through a feeding tube.
The family managed to secure a year's supply of the formula thanks to Dischem following an earnest plea on social media as their medical aid Discovery, does not cover the exorbitant costs for the formula.
The twins' doctor, Anell Meyer, has made motivations to the medical aid scheme to request that it pays for the formula.
She says the diagnosis is a complex case and that Neocate is key to the twins' survival.
Unfortunately, in their case, we had to switch to a 23-hour routine where we constantly have to trickle the feed in to keep them nourished and to prevent any obstruction complications. It is the only treatment available.Dr Anell Meyer
Head of the clinical policy unit at Discovery Health Dr Noluthando Nematswerani explains why they are unable to cover the treatment, despite having offered the twins funding last year.
When we review fees, we look at the clinical circumstances of each individual case... the case was presented to our clinical team and these boys were offered funding for Neocate as a clinical exception.Dr Noluthando Nematswerani, Head - Discovery Health clinical policy unit
When we look at clinical exceptions we need to ensure that we are fair. If you were to sit on this side and see the number of requests we get for various conditions, it is all compelling reasons and indications that the doctors will put forward. We need to then put policies in place to make sure the funding is consistent and fair for the rest of the membership...Dr Noluthando Nematswerani, Head - Discovery Health clinical policy unit
It is not right for listeners to be misled to think this is about money-making. A scheme is a not for profit organisation. What we do as the administrator is to ensure that whatever funding we provide is in accordance with the rules of the scheme. What we have done for the Sim twins is to actually look outside of the rules and say can we make a clinical exception...Dr Noluthando Nematswerani, Head - Discovery Health clinical policy unit
Nematswerani explains that they have stopped funding the twins because the clinical exception has an "entry and exit criteria".
At a certain point, evaluating the clinical condition of the twins, it was felt that normal scheme rules should continue to apply but should the condition change, we would then still look at it as a clinical exception.Dr Noluthando Nematswerani, Head - Discovery Health clinical policy unit
Click on the link below to hear more...
This article first appeared on 702 : [LISTEN] Discovery explains why it's unable to cover treatment for Sim twins
The scuffle took place at the EFF elective conference where Julius Malema and Floyd Shivambu were re-elected to top positions.Read More
The party is holding its national elective conference at Nasrec this weekend amid a row over media accreditation.Read More
A High Court judge has extended an interdict stopping law enforcement officials from issuing fines and harassing homeless people.Read More
Department of Home Affairs spokesperson, Siya Qoza, explains how the power outages affected services to verify identities.Read More
The High Court has dismissed the Public Protector's application for leave to appeal the Estina Dairy Farm report ruling.Read More
Political analyst Ralph Mathekga looks at the upcoming Economic Freedom Fighters National People’s Assembly starting on Friday.Read More
Premier Alan Winde and ANC's Cameron Dugmore are behind Matakata, who's tasked with bringing stability to policing in the province.Read More
Refilwe Moloto interviews Marks on her first visit to Cape Town since taking up her new role.Read More
Sarb Governor Lesetja Kganyago highlights responsibilities of Reserve Bank and why interest rates are a tool not policy objective.Read More
W Cape MEC for Community Safety Albert Fritz discusses the new appointment of Yolisa Matakata as the top cop in the province.Read More