SECTION27 is becoming increasingly aware that some medical schemes try to narrow the scope of the benefit options they offer when it comes to processing claims. This may be done, for example, by mischaracterising claims so that they fall outside benefit options, improperly imposing late joiner penalties and waiting periods, or failing to cover prescribed minimum benefits as required by law. Such practices are unlawful and violate the rights of scheme members who are forced to incur out-of-pocket medical expenses in circumstances where they are covered by their benefit options. In some cases, they may also be prevented from accessing necessary health care.
Our client, IE, has been HIV positive for 20 years and participated in early trials of antiretroviral (ARV) medicines before the conventional treatment regimens became available. As a result of his exposure to various ARV medicines and regimens over an extended period, IE began to develop fatty growths on his back and neck and was diagnosed with ARV-related lipodystrophy. On the recommendation of his physician, IE applied to Bonitas Medical Fund (Bonitas) for authorisation for the surgical removal of the fatty growths on his body.
Bonitas, however, refused to cover the medical procedure on the basis that it considered the procedure to be cosmetic surgery. There was no medical basis for this decision. Bonitas failed to consider all the relevant information before it and mischaracterised the claim as cosmetic in order to avoid its legal obligation to cover IE’s costs. Following SECTION27’s intervention on behalf of IE, the claim was authorised with retrospective effect and IE was reimbursed most of his out-of-pocket expenses.