VC
Vonne C
Active since Jul 2025
2
Reviews
0
Industries
Reviews
2 reviews9 months ago
Genesis Medical Scheme not wanting to help after my PMB cancer win at the CMS so they trough me out and i am not the only one.
Dear Ian Hughes and Katherine W my name is Vonne Conradie and I would love to make contact with you. Please find me on Facebook. My story was published in Die Rapport and it is exactly the same as yours. I would also love to speak to the Citizen, The Sunday times and Carte Blanche as well.
0 replies
9 months ago
GENESIS MEDICAL AID NOT WANTING TO ASSIST PATIENT WITH TREATABLE PMB BREAST CANCER
Hallo, my naam is Vonné Conradie en die is my storie van hoe my mediese fonds, my en my gesin se lewe hel gemaak het. In die middel van 2024 het ons as n gesin besluit om n hospitaal plan te kry, dit is nou vir my en my man, my dogter en my seun. Ons het besluit op Genesis Medical want hulle het was bekostigbaar en hulle was goed geadverteer en voorgeskryf deur verskeie instansies insluitend Bok Radio waar ons eerste van hulle gehoor het. Ons het apart vir beide ons kinders en ons aansoek gedoen en is baie spoedig aanvaar en ons was baie gelukkig met hulle diens. Toe in die begin van November 2024 het my man, Hein, n knop in my linker bors gevoel. Ek is toe na onmiddelik na my huis dokter en hy het my dadelik vir n mammogram gestuur. Ek het toe gegaan, wat n ongemaklike storie. Ek het vir 2 uur sit en wag vir die uitstale – ek kon sien vroue wat na my na daar aan kom vining in en uit is. Ek het sit en wag vir 2 ure, en binne my het ek geweet daar is fout. Die dokter wat die scans geaniniliseer het, het my geroep en vir my gesê ek moet so gou moontlik gaan vir n biopsie. Ek vra haar toe wat fout is en sy het gesê ek moet dit laat toets, maar ek moet nie te veel worrie nie. Ek kon sien in haar gesig sy is bekommerd. Sy het my die uitslae gegee en is dadelik terug na my huis dokter en hy het vir my gesê dit lyk soos kanker. Om sulke nuus te kry ia vreeslik, dit voel of die mat onder jou voete uitgeruk word. My hele lewe het tot stillstand gekom. Skok, angs en onsekerheid was die 3 hoof gevoelens wat oorgeneem het. My man was net so geskok soos ek, jy hoor altyd van ander mense wat so iets deurmaak, maar ek meen wat is die kanse dat ek so iets sal oor kom? 1 in 8! En ek is die 1. Hoe is dit moontlik? Wat het ek dan gedoen wat so erg verkeerd was? Hoekom word ek so gestraf en gaan ek ok wees? Gaan ek die ding wen en gaan ek weer n ‘normale’ mens wees? Wat is normal na so n diagnose? Hoe maak jy asof alles ok is en sal wees as jy skaars kan asem haal. Dadelik lees jy so veel jy kan en met n sterk mediese span, mediese fonds, sirkel van vriende en familie gaan jy ok wees, so sê hulle…. Hoe nou, wat maak ons om van die kanker onslae te raak? Gelukkig het ons in Augustus 2024 aangesluit by Genesis Medical en het ons n hospital plan. Wel n biopsie is stap no1. Ek is verwys na Dr. Roux by Netcare Kuilsrivier en wat n wonderlike mens. Hy het my ondersoek en gesê hulle sal reël met ons mediese fonds, Genesis Medical, om die biopsie te doen. Genesis se eerste antwoord vir die biopsie was nee. Hulle het n mediese geskiedenis van my verlang voor enige besluite geneem sal word. Dr. Muller-Botha het n 2 jaar opsomming van my geskiedenis aan hulle gestuur. Genesis was nie gelukkig daarmee nie en vra toe vir n volledige ver**** van my geskiedenis by hom – dit is van 11/11/2013. Die rede daarvoor was da tons redelike nuwe lede was. Asof ek kanker vir n klomp jaar weggesteek het nou skielik dit wil behandel, dis absurd. Nogsteeds was hulle nie gelukkig met my geskiedenis nie en hulle vra toe vir Hein se geskiedenis, wat ons tot vandag toe nie verstaan nie, want toe ons aansoek gedoen het vir die fonds het hulle niks sulke vra gevra nie. Is dit dan nie juis wanneer jy dit moet doen nie. Ek is ges***el deur Genesis Medical se onkologie afdeleling en is gevra hoekom ek vir n biopsie wil gaan, want volgens my geskiendenis is daar geen kanker in my lyf nie – ek het geen woorde gehad nie en gevra of die oproep opgeneem word want dit is die domste vraag wat ek nog gehoor het. Na weke se heen en weer vir die biopsie het hulle uiteindelik besluit ek kan dit kry en dit was toe gereël vir die 11/12/24. Dit was 1 van die seerste prosedures wat ek nog beleef het. Dr. Roux het 5 keer n sample geneem en dit is weg gestuur vir ontleding. Dr. Roux wou my toe 2 dae later weer sien en dit is toe hy bevestig dat dit wel kanker is en dat ek na Dr. Marie Engelbrecht, van Mountainview Onkologie gestuur gaan word. Sy is wonderlik – ek noem haar dokter vetplant – haar spreek kamer is vol vetplantjies – dis pragtig! Ons het haar gaan sien die 24ste Desember, Oukers dag, en hulle wou my vir n CT scan stuur om te sien of daar enige ander kanker groeisels in my lyf was n week later. Sy het ons ingelig die kanker behoort te val onder n Voorgeskrewe Minimum Voordele (PMB), omdat dit borskanker met Her 2 + was. Volgens Dr. Mari sou al die scans en toetse alles onder die PMB voordele val en die mediese fonds sou verandwoordelik wees daarvoor. Soos met die biopsy het Genesis gesê nee hulle gaan nie betaal nie, want ons hospital plan het nie scans buite die hospital gedek nie en ons moes n klomp geld betaal vir die CT scan. Dit was die moeilikste Kersfees wat ons nog beleef het. Om met die onsekerheid te probeer normaal wees is net onmoontlik. Intussen het ons probeer om ons plan by Genesis Medical te verbeter na die volgende opsie ,maar weens die feit dat ons te laat was met ons aansoek. Dit moes voor die einde van die jaar wees maar ons het ons aansoek op die 2de Januarie gestuur. Ek het toe gegaan vir die CT scan en Dr Mari wou my weer sien. Toe ons by haar kom het sy ons ingelig daar is n 2de groeisel op my skildklier was en hulle sal dit ook moet biopsie om te sien of dit kwaadaardig is. Weer is my wêreld geruk en ek ek het gevoel of ek wil dood. Wat kan dan nou nog verkeerd gaan, hoekom en waarom is die vra wat in my kop was. Ek wil nie meer nie en ek weet nie of ek nog slegte nuus kon verdra nie. Verder het Dr Roux aansoek gedoen vir die mastectomy en dit was sommer gou goedgekeur, wat my stom geslaan het – ek het gedink hier kom n groot baklei, maar toe nie. Ek moes toe gaan vir Nuclear Isotope behandeling die dag voor die operasie, sodat hulle die lymph kliere kon sien. Weereens het Genesis gesê hulle gaan dit nie betaal nie, wat geen sin maak nie, want sonder dit kan die operasie nie gebeur nie. My man en die dokters het toe weer vir Genesis genader oor die behandelig wat hulle afgekeur het en toe het hulle dit wel goedgekeur. Ons moes ook toe aansoek doen vir die 2de biopsie vir die groeisel op die skild klier wat 5 dae na die masektomie sou gebeur en dit was goedgekeur sonder enige probleme. Ons het toe voortgegaan en die operasie is gedoen. 16/1/25. Die dag toe ek n halwe vrou geword het, n pop wat kinders vermorsel het, iets wat ek tot vandag nog nie ii die spieël kan bekyk nie. Ek was dadelik op na die opersasie en het so veel as moontlik beweeg sodat ek kon huis toe gaan. Na my plek waar ek kon rou en myself weer kon kry in my kop. Dr Mari het die hele mediese plan na Genesis Medical gestuur vir my chemo behandeling wat so gou moontlik moes begin omdat dit n aggresiewe kanker is. Weereens het hulle nee gesê. Hulle rede die keer was dat ons plan, MED100, het nie kanker behandeling gedek nie. Dit het vir ons nie sin gemaak nie, want volgens Genesis Medical word PMB kanker wel gedek by publieke hospitale. Dr. Mari Engelbrecht het vir ons gese dat onder n PMB kanker kan sy dit behandel solank hulle kostes in lyn is met die bepaalde kostes van die MSA. Die kwotasie wat sy gestuur het aan Genesis Medical was in lyn met GEMS se kostes. Tussen my man en Mountainview Onkologie het hulle vir Genesis Medical ge****ak om te probeer sin maak hoekom hulle dit afkeur. My man het toe epos na epos gestuur om te probeer reel dat ons my behandeling kan begin so gou moontlik en by die tyd het ons nog geglo ons kan dit doen by Mountainview Onkologie. My man het op die stadium vir Genesis Medical gevra dat as ons kies om die behandeling te kry by Mountainview Onkologie instede van TBH wat sal die addisionele kostes wees wat ons moet inbetaal. Al wat Genesis Medical op die stadium gese het was dat ons plan net PMB kanker behandeling doen by staats hospitale. Die 2de biopsie is toe gedoen die 21ste Januarie 2025 by Netcare Kuilsrivier deur Dr. Plekker, prys die Here die een het negatief terug gekom en ons kon nou al ons ***us sit op die Chemo behandeling. Omrede Dr. Mari vir ons gese het dat my vrou se behandeling so spoedig moontlik moet begin het my man aanmekaar vir Genesis Medical ge****ak daaroor. Hy het gevra oor wat die verskil sal wees tussen die PMB goedgekeurde koste en dit wat Mountainview Onkologie gevra het want Genesis Medical het gese ons sal verantwoordelik wees vir die addisionele kostes as ons besluit om my vrou na Mountainview Onkologie te stuur. Die volgende paar weke was n aanhoudende storie van epos op epos en telefoon gespek na telefoon sprek om duidelikheid te kry oor die Chemo. DIt het later aan duidelik geword dat Genesis Medical nie vir die behandeling wou betaal nie en op die 21ste Februarie 2025, n volle maand na my vrou se 2de biopsie het ons n brief ontvang vanaf Genesis Medical, deur D van der Merwe, Genesis Medical se Principal Officer. Sien hieronder die inhoud van die brief 21 February 2025 Mr HF Conradie 9 Seaview Cal-De-Sac Mountainside Gordons Bay 7140 Transmitted via email: hein@pikes.co.za Dear Mr Conradie YOUR MEMBERSHIP: 05263454 BENEFITS: MED-100 OPTION 1. We refer to various emails sent to the Scheme regarding the benefits available to you as prescribed in the registered rules (“the Rules”). You clearly have knowledge of the law and so we will not enter into any legal debate with you. 2. That said, we express our surprise that you have elected, seemingly, to have no regard to the provisions of section 32 of the Medical Schemes Act (“MSA”). 3. In addition, the provisions of section 29(1)(p) of the MSA are clear and easy to understand. You state, seemingly as a fact and without reference to any evidence, that your wife’s illness is a PMB. Perhaps you have overlooked the provisions of section 29(1)(p) of the Act in regard to the specific conditions pertaining to the reimbur*****t of any such treatment. 4. You must surely be aware that illnesses are listed as PMB’s only to determine the level of reimbur*****t that medical schemes are liable for. The fact that an illness is listed in Annexure A as a PMB does not by any stretch mean that medical schemes must reimburse claims without limit. The treatment is prescribed by regulation, and the level of reimbur*****t is determined by where the treatment is administered. 5. In addition to everything said above, you must also surely know that cancer of the breast is only listed as a PMB if treatable. Confirmation of this fact is found in Annexure A to the regulations to the MSA at DTP 950J. 6. Explanatory note 3 to Annexure A to the regulations to the MSA provides a clear explanation of the legal meaning of “treatable”. In terms of information available to the Scheme, your wife’s cancer has spread to adjacent organs and, as such, her illness is not “treatable” as defined by law. Obviously, cancer is treatable in the clinical sense but that does not mean that Genesis has any obligation in law to reimburse claims associated with that treatment. The Scheme’s financial obligation is determined by the terms of the contract entered into by you. 7. When you app**** for membership of Genesis, you declared that you had read the Rules and that you agreed to be bound by them. In addition, you elected membership of the MED-100 benefit option that asks a lower contribution in return for lower benefits. Put differently, your traded off lower benefits in exchange for a lower contribution. 8. It appears from your correspondence that you expect the same benefits as other members of Genesis that pay a higher contribution. On that basis, it is surprising that every member of Genesis does not elect to pay lower contributions in the expectation of higher benefits. 9. You must also surely be aware of the Appeal Board of the Council for Medical Schemes’ ruling in the matter Genesis Medical Scheme v DG (2024) when Judge Masipa held: “[61] The Legislature could never have intended that a member with low contributions would be entitled to exactly the same benefits as a member with high contributions. In any event, the scheme cannot be directed to make funding contrary to the provisions of its registered rules [62] In the present case, G signed for a membership of the Private Choice [now MED-100] benefit option, an option that has concomitantly lower benefits than other options. He cannot, on his membership, expect unlimited benefits.” 10. Your correspondence contains a slew of incorrect statements. In light of what is said above and the clear legal provisions that support our position, no point will be served in addressing same. 11. We are aware of a letter written by Dr Mari Engelbrecht addressed “To whom it may concern”. In her letter, Dr Engelbrecht makes a legally and factually baseless statement that Genesis has an “ethical and legal obligation” to treat your wife. Dr Engelbrecht is correct that Genesis has a legal obligation that extends to ensuring that it applies the law equally to its members. Dr Engelbrecht unfortunately produces no evidence in support of her legally baseless personal opinion. It is perhaps Dr Engelbrecht who has an ethical obligation to treat your wife, seemingly only on condition that she is paid for her service. Genesis does not treat patients. Dr Engelbrecht may wish to consult a competent lawyer well versed in medical schemes law and procedure before making any further such pronouncements. 12. In all of the circumstances referred to above, if you are able to produce evidence that Genesis has breached a Rule or that it has breached a section of the MSA, then we invite you to forthwith submit your evidence to the Scheme for investigation. You will know that the term “complaint” is defined in section 1 of the MSA and you will need to produce the evidence should you not be satisfied with the provisions of the law as promulgated by Parliament. 13. We trust that what is said above answers your questions. Yours sincerely D. van der Merwe PRINCIPAL OFFICER Transmitted electronically without a signature. U sal merk in punt 6 dat Genesis Medical hier verklaar dat die kanker verspei het na die volgende orgaan en dat ek onbehandelbaar is. Die volgende orgaan volgens hulle is my lymph kliere. Die obsolute skok en trauma wat my getref het daai dag was onverstaanbaar, wat dink mens as iemand vir jou se hulle gaan jou nie help nie want die kanker is onbehandelbaar. Hulle kan niks vir jou doen nie, hulle kan jou nie help nie – Hoeveel tyd het ek oor? My man het natuurlik dadelik n epos terug gestuur aan Genesis, sien asseblief hieronder die epos gerig aan Genesis Medical op die 21ste Februarie 2025 ten opsigte van die brief ontvang hier bo. Hi Lauren, Please see my replies to the various points listed in the attached letter addressed to me from D van der Merwe. 1. As to point number 1 the only knowledge that I have of the rules is what I have read in various documents sent to me by Genesis, I am not a lawyer. 2. However you clearly state in point 1 that you are not entering into a legal debate with me, but most of what was said after is legal statements from the Medical schemes act which I, as a “normal person”, have not studied. 3. Over the next few points you kept on going deeper into the legal points listed in the MSA leading up to stating that according to law her illness is “not treatable” do you have any idea as to what a statement such as that does to the mental state of a person? I have come to the conclusion that somewhere during all this communication the point we have been trying to make has been lost, so please bear with me as I try to clarify what we are asking. When we read through your documentation we saw and clearly understand that chemotherapy and radiation etc. under MED-100 will be done at a state facility. It is also stated that if we choose to have the treatment done at a private facility you will only pay out the MED-100 rates as set out by Genesis and that any additional payments will have to be done by the member, which will be me. We agree with all of this and we have never asked for anything more than what we are covered for, we only requested to have my wife treated at Mountainview Oncology, according to the documents we received you will then only pay them 100% of the tariff set out by Genesis and any additional amounts will be our responsibility. Mountainview Oncology then submitted an quotation for the treatments which came to R10,413.40 per cycle, my question was then how much is the difference between Genesis MED-100 tariff and the quoted amount. This was so that we could judge if we would have enough capital to cover the outstanding balance due, if any. I could not get an answer to this question and it was at this point where I got frustrated with the answers I was not getting, I am sorry about that. In short, we do not want anything more than what we are covered for, but if we need to pay in additional fees I would like to know how much it will be, I hope you understand. As to our MED-100 plan, I did try to up our cover twice, I contacted Genesis in October of last year to try and up our cover to MED-200. I was then informed that we can only do it at the start of the new year. I then again contacted Genesis at the beginning of 2025 on January the 2nd even before our first payment went off. I was then informed that if I want to upgrade I need to do it after the 20th of December and before the start of the new year. I did however submit an application on the 2nd of January but was declined on the 8th of January. Kind Regards Hein Conradie Hier sit ek toe met geen hoop nie, want daar is gese ek kan nie behandel word nie, my man het weereens probeer n antwoord kry by Genesis oor my Chemo behandeling maar na sy laaste epos, hierbo, het ons die volgende brief ontvang vanaf D van der Merwe by Genesis Medical, sien hieronder 25 February 2025 Mr HF Conradie 9 Seaview Cal-De-Sac Mountainside Gordons Bay 7140 Transmitted via email: hein@pikes.co.za Dear Mr Conradie YOUR MEMBERSHIP: 05263454 BENEFITS: MED-100 OPTION I refer to you email dated 21 February 2025 and have taken note of your understandable frustration. The world of medical schemes is unfortunately clothed in legal matters that are not of our making. None of what I have said is of any assistance or comfort to you, but the fact nevertheless remains, that this is the reality of the situation. Medical schemes are creatures of statute whether we like it or not. Doctors live in an entirely different world of treating and curing illnesses. Medical schemes do nothing more than reimburse claims that qualify for such in terms of the legal contract entered into with members. In regard to your wife’s unfortunate illness, the facts are that her cancer has spread to adjacent organs. In terms of the law (not what doctors will tell you, but the law that entitles you to benefits from Genesis), the cancer is not treatable in the legal sense. This means that even if your wife seeks treatment at a public hospital, the treatment will not qualify for funding as the diagnosis is that of a disease that the Government has decided is not treatable. The way the law is structured, an illness that is listed as a PMB qualifies for funding if treated at a public hospital and then, and only then, the treatment must be as prescribed by regulation. Otherwise, the treatment does not qualify for reimbur*****t as a PMB. When treatment is obtained from a private or non-state hospital, the benefits prescribed in the rules of the medical scheme apply. In your case, the MED-100 benefit option contains no benefit for the treatment of cancer out of hospital. This all means that even if your wife seeks treatment at a public hospital her claims will not be paid as her cancer has spread to adjacent organs. If she seeks treatment at a private hospital she will also not qualify for benefits as the MED-100 option that you chose does not include any benefits for out of hospital treatment. 2 What is said above is the law that is binding on Genesis and all of its members. This is not what you want to hear but it is unfortunately the reality of the situation in which we find ourselves in. We have no choice but to apply the law and whilst doctors sometimes adopt a different view, we have taken extensive legal advice and we are comfortable with our position. I readily accept that you may not have access to the regulations and so I have taken the liberty of including the Explanatory notes to the regulations as they apply to treatable cancers: (1) “Treatable” cancers – In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where: i. they involve only the organ of origin, and have not spread to adjacent organs ii. there is no evidence of distant metastatic spread iii. they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by cerebral tumour) or another vital organ iv. or, if points (i) to (iii) do not apply, there is a well demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned” (emphasis added). In all of the circumstances set out above, the Scheme cannot admit any claims for treatment out of hospital for your wife. This is surely not the response that you want to have but it is the law, and the terms of the contract entered into by you. We sincerely wish your wife well with her treatment. Yours sincerely D. van der Merwe PRINCIPAL OFFICER Transmitted electronically without a signature. Dit was toe na die laaste brief vanaf Genesis Medical wat ons besluit het om die Medical Council te nader vir hulp. Op die 25ste Februarie 2025 het ons n epos gestuur aan die Medical Council waarby ons vra vir hulp. Hlle het dadelik geantwoord en ons het toe n formele klag ingedien dieselfde dag. Op die 26ste Februarie het ons dan n Klag nommer 87231 ontvang vanaf die Medical Council. Met al die sloer van Genesis moes ons nogsteeds ***us hou want ek moes binne 8 weke na die masektomie begin met die chemo anders was dinge te laat vir my. Dr. Marie Engelbrecht van Mountainview Onkologie het toe ****ak gemaak met TBH om te reel vir chemo behandeling want ek het gaan ander opsie gehad nie. Dit het beteken ek en Hein moes 4 uur opstaan om 5 uur daar te wees sodat ons tenminste teen 9 uur gehelp kon word, ek het dadelik met die Doxorubicon (die rooi duiwel) begin, n baie aggresiewe chemo – ek het binne n maand al my hare verloor en dit het my baie siek gemaak. Ek het 4 behandelings elke 3 weke gekry ek was naar die hele tyd en kon nie eet nie, erg diarrhea gehad vir maande, mond sere, was moeg die hele tyd en dronk in my kop maar ek dink die ergste is die feit dat my are in my arms weefselskade aangedoen het. Dis vir my moeilik om normale dag tot dag goed te doen sonder om pyn in my arms te he. Moet my asb nie verkeeerd verstaan nie Tygerberg Hospitaal het my gehelp maar ongelukkig is hulle oorvol en die hele rede vir PMB behandeling is dat mense met n mediese plan die stress op die staat sisteem n bietjie ligter kan maak, daar is mense wat in die gange sit en chemo kry omdat die saal net te vol is. Kan die mediese fondse dan nie help nie – dit nie makliker maak vir daai mense nie? Ook saam met al die het Genesis vir ons laat weet dat hulle wel die rekeninge van Tygerberg Hospitaal gaan betaal maar ons moet hulle terug betaal anders vind hull eons in “breach of Contract” wat beteken hulle kanseleer ons ****rak by hulle wat alle verantwoordelikheid van hulle sal verwyder. In my boek is dit n form van afpersing. Hoe kan jy iemand dreig met n hulpmiddel? Dan wil ek ook weet wat is die kwalifikasies van die mense wat die besluite neem oor ons gewone mense op straat en bo dit alles hoe slaap jy in die aand met die wete dat jy met iemand se lewe speel? Dan op die 30ste Mei 2025 het ons die uit**** ontvang van die Council of medical schemes wat ons ingedien het op die 25ste Februarie 2025, 3 maande later MAAR ONS HET DIE SAAK GEWEN! Sien brief hier onder MR H CONRADIE ON BEHALF OF MS V CONRADIE AND GENESIS MEDICAL SCHEME Reference: CMS87231 Date: 30 May 2025 COMPLAINT RULING: CONRADIE // GENESIS MEDICAL SCHEME 1. This complaint was referred to the Registrar by Mr H Conradie (‘the Complainant’) on behalf of Ms V Conradie (‘the member’). The complaint concerns the funding decision of Genesis Medical Scheme (‘the Scheme’) regarding the member’s breast cancer treatment. 2. The Complainant alleges that the Scheme is declining to approve funding for his wife's breast cancer treatment specifically chemotherapy. 3. The complaint was referred to the Respondent in terms of Section 47(1) of the Medical Schemes Act, 1998 (Act No. 131 of 1998) which is being referred to herewith as the Act. In its response to the complaint, the Scheme the Scheme indicated that the matter forwarded to it terms of Section 47(1) is not a complaint as defined in the Act. It indicated that the Complainant failed to make reference to any section of the Act or a rule that was allegedly contravened. 4. The Scheme also made reference to a ruling between Liberty Medical Scheme v M (2016), and advised that according to this ruling, it was held that the moment the Registrar ventures beyond the issues raised in the complaint and actually in dispute, he acts in breach of Section 47(1) of the Act and his Ruling cannot be sustained. Be that as it may, the Scheme continued to respond to the allegations stated by the Complainant. 5. The Scheme submitted that MED-100 benefit option does not include any out of hospital benefits. That Cancer of the breast is listed as a PMB only when it is “treatable” as defined by Regulations. According to the Scheme, the histology reports indicate that the cancer has spread to adjacent organs and it is, accordingly, not treatable as defined by Regulations. 6. The Scheme also added that if member seeks treatment at a public hospital, her claims will not be paid as her cancer has spread to adjacent organs. That if she seeks treatment at a private hospital she will also not qualify for benefits as the MED-100 option does not include any benefits for out of hospital treatment. Point in limine 7. In its response, the Scheme alleged that the complaint forwarded to it in terms of Section 47(1), is not a complaint as defined in the Act. Although we have addressed this matter in past rulings to the Scheme, before we proceed with the evaluation of the facts, we will consider this issue as a point in limine. 8. Section 1 of the Act defines a complaint as: “complaint” means a complaint against any person required to be registered or accredited in terms of this Act, or any person whose professional activities are regulated by this Act, and alleging that such person has— (a) acted, or failed to act, in contravention of this Act; or (b) acted improperly in relation to any matter which falls within the jurisdiction of the Council; [own emphasis] 9. The Scheme alleges that the Complainant failed to produce evidence of contravention of any of its registered rules or provisions of the Act. This argument by the Scheme is incorrect in that according to the above definition, all that a complainant needs to do, is to make an allegation. The Act does not require complainants to produce evidence to the Registrar. What the Act does at section 47 is to require the Registrar to forward full particulars of the complaint to the party complained against. The Act does not however define what the full particulars are and in our view, the submission of the complaint form containing the relevant allegations, and clinical information supporting a specific request, is sufficient to prompt the referral of the matter to the party complained against. The substantive value of information submitted by a complainant is considered by the Registrar once the other party has responded to the complaint. Whether an allegation is true or not is tested via various processes mentioned in Section 47(2), 48, 49, and 50 of the Act. 10. The Legislature is alive to the fact that not all beneficiaries of a medical scheme will be legally trained or able to navigate the legal jargon in the Act. It is our view that the Legislature would not have placed a strict requirement on beneficiaries by insisting on quotation of provisions of the Act before their matters could be attended to as this would be tantamount to denying lay members their right to lodge complaints. One of the main purposes of the Act is to protect the interests of beneficiary and in our view, the Legislature would not have placed a burdensome onus on members as this would have deterred them from exercising their rights to lodge a complaint and resulted in medical schemes and other accredited entities, avoiding accountability. 11. Furthermore, the Appeal Committee confirmed in its ruling between GEMS and Bonitas v Registrar 1 that a medical scheme is not compelled to respond to a complaint sent to it in terms of Section 47(1), the committee indicated that all what this section does is to place an obligation on the Registrar to forward the complaint to the party concerned. Whether a medical scheme responds or not is purely its choice however the Act places an obligation on the Registrar to resolve complaints and the Registrar must comply with this obligation. 12. To substantiate our stance, we will provide an example of complaints related to payment of claims. Section 26(1)(b) and (c )(i) of the Act provides the rationale behind the funding liability of a medical scheme. These provisions indicate that a medical scheme will assume liability for and guarantee the benefits offered to its members on condition that members pay contributions. Medical Scheme pay claims and offer other benefits because members pay contributions. Therefore, when a member lodges a complaint alleging that claims are not paid, we do not expect a member to allege that a medical scheme contravened Section 26(1)(b) and (c )(i) of the Act in that it failed to keep its end of the bargain, because the allegation that claims are not paid is sufficient for us to know that various provisions are involved, including Section 26(1)(b) and (c )(i) ,Regulation 8(1) and a possible scheme rule. Such complaints have been attended to and it was found in some of them that indeed there was contravention of the Act/scheme rule. 13. The determination of whether a matter is a complaint or not, lies with the Registrar and not a respondent. If the determination was made by respondents, this would lead to a serious miscarriage of the intention and objectives of the Act. This would also result in a lack of accountability by accredited entities because all complaints would be viewed as baseless. - 1 Gems and Bonitas v The Registrar CMS 53221 Issued 9 July 2018 14. Furthermore, the Liberty ruling mentioned by the Scheme finds no place herein because while the ruling addressed instances where the Registrar ventured into matters not raised by the Complainant, in this case, the Complainant alleged non-payment of cancer treatment and this is the very issue that is addressed herein and nothing further. 15. On the basis of our discussion above, we find that the matter is a complaint and the argument by the Scheme is dismissed. 16. The issue for adjudication is therefore whether the Scheme is correct to decline the member’s chemotherapy on the basis that her cancer has spread and is not treatable. 17. The establish the funding obligation of the Scheme in this regard, the CRC was requested to advise whether the member’s condition is a PMB and if so, whether the requested chemotherapy was PMB level of care for the condition. 18. Having considered the clinical information provided, the CRC advised as follows: “ICD10 code C50.9 – “Malignant neoplasm, breast, unspecified” is a Prescribed Minimum Benefit (PMB) condition under Diagnosis and Treatment Pair (DTP) code 950J if the cancer is treatable. Point 3 of the Explanatory notes and definitions to Annexure A of the PMB Regulations specifies that “Treatable” cancers. —In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where: (i) they involve only the organ of origin, and have not spread to adjacent organs (ii) there is no evidence of distant metastatic spread (iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ (iv) (iv) or, if points (i) to (iii) do not apply, there is a well demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned. Dr Roux (Specialist Physician) stated that the patient presented with a 1-month history of a left breast mass without pain, discharge, or skin changes. A mammogram revealed a BIRADS 4c lesion at the 12 o’clock position. She has a history of bilateral breast reduction surgery. Clinical findings indicate early-stage breast cancer (T2N0Mx), with a 2x2 cm peri-areolar mass and a negative axilla. A tru-cut biopsy was performed on 11 December 2024, with provisional histology provided. The patient has been informed and counselled and is a candidate for primary surgical resection; adjuvant therapy is yet to be decided. Dr Engelbrecht (Clinical & Radiation Oncologist) indicated that the patient was recently diagnosed with locally advanced, HER2-positive breast cancer. Histology confirmed the diagnosis, and pathology reports revealed involvement of the axillary lymph nodes. Delaying her treatment could worsen her prognosis by increasing the risk of metastasis and reducing long-term survival. Although the medical aid prefers state sector treatment, high patient volumes there may cause harmful delays, which are particularly dangerous for her locally advanced cancer. In the South African Oncology Consortium (SAOC) form from Tygerberg Hospital dated 06 March 2025, a diagnosis of Grade 3 Left Breast Carcinoma, diagnosed on 11 December 2024 was confirmed. Invasive Breast Cancer, No Special Type (NST) with Pleomorphic features. • Staging: pT1c N1a M0 o Stage 2A • Mastectomy and axillary lymph node dissection (ALND) done on 16 January 2025. • Treatment prescribed for radical intent: o Neoadjuvant chemotherapy: Adriamycin and Cyclophosphamide every 3/52 x 4 o Then Docetaxel every 3/52 x 4 o Herceptin to start with Docetaxel loading dose o Herceptin maintenance for 17 cycles Conclusion Based on the SAOC form provided, the member was diagnosed with a Grade 3, Stage 2A Left Breast Cancer The Pathologic Tumor Size (pT1c) was between 1 and 2 cm in size, there was spread to 1 -3 nearby lymph nodes, but there was no spread to distant organs. Considering the information provided, there is no evidence of metastasis, and the cancer is therefore treatable and PMB condition under DTP code 950J. Treatment component specified for DTP code 950J is “Medical and surgical management, which includes chemotherapy and radiation therapy”. In this case, the following treatment is therefore PMB level of care for the member’s condition: o Neoadjuvant chemotherapy: Adriamycin and Cyclophosphamide every 3/52 x 4 o Then Docetaxel every 3/52 x 4 o Herceptin to start with Docetaxel loading dose o Herceptin maintenance for 17 cycles (Trastuzumab is a biologic medication and is PMB level of care in this case because the member has HER2 positive breast cancer).” [own emphasis] 19. The CRC has indicated above that the clinical information provided supports that the member’s condition is treatable and thus a PMB. The CRC also provided the treatment that is considered PMB level of care for the condition. It therefore follows that the Scheme’s assertion that the member’s condition is not a PMB, is incorrect. Since Regulation 8(1) of the Act places an obligation on medical schemes to fund claims related to the diagnosis, treatment and care costs related to a member’s PMB condition, the Scheme must fund accordingly. Regulation 8(1) also indicates that PMB claims must be funded in full irrespective of the benefit option of the member. The Scheme cannot therefore use its benefit option or rules to deny a member benefits which have been entrenched in the regulations of the Act. Therefore the fact that the member’s benefit option ( MED-100) does not offer any out of hospital benefits, is irrelevant in this regard. 20. Furthermore, where PMBs are concerned, the fact that a member chose a cheaper benefit option(sic), is without weight because PMBs are paid in line with the Act and not scheme benefits. This also implies that any limitation to the benefits, must be in line with the Act, eg Regulation 8(2), Regulation 8(3), etc. 21. Having considered all of the above, the Registrar finds that the Scheme is liable for funding the member’s PMB level of care treatment in line with the provisions of Regulation 8. 22. This decision is binding on both parties save when an aggrieved party appeals against the decision to the Council in terms of the provisions of Section 48(1) of the Act. An appeal contemplated in terms of subsection (1) shall be in the form of an affidavit directed to the Council and shall be furnished to the Registrar not later than three months, or such further period as the Council may, for good cause shown, allow, after the date on which the decision concerned was made. The notice and grounds for appeal should be sent to appeals@medicalschemes.co.za. Upon receipt of your notice to appeal the matter will be referred to the Secretariat of the Appeals Committee who will schedule the matter for hearing before the Appeals Committee of Council in due course. You are cordially requested to quote reference number CMS 87231 on all correspondence related to this complaint. Kind regards Lebogang Mokalake Senior Legal Adjudication Officer OFFICE OF THE REGISTRAR Dit het beteken ek kon na Dr. Mari gaan want die Council het bevestig dit is n PMB, ek is behandelbaar en dat Genesis Medical vir alles volgens National Rates sal moet betaal. (Wat Dr Mari vra.) Ons het besluit om haar te gaan sien en sy het dadelik n afspraak gemaak by Dr Roux en hy het n afspraak gemaak vir n port om ingesit te word. Dit beteken ek sal my are in my arms kan spaar – die fonds sal dit moet dek aangesien dit n PMB is. Weereens het Genesis Medical nee gese – ons moet dit self betaal – hulle dek niks. Die uitspraak van die Medical Council kan “appeal” word. So basies wat hier gebeur het is dat die Medical Council het gekyk na al die informasie en hulle het besluit dat dit wel n PMB is. Alhoewel dit gebeur het, het niks verander nie, Genesis het net besluit hulle gaan appelleer waarvoor die Medical Council vir hulle 3 maande gee. Genesis het klaar vir ons gese hulle gaan appelleer maar hulle het nog niks vir die Medical Council gestuur nie, want hulle het 3 maande om dit te doen. Ek verstaan dit nie, hoe kan Genesis Medical besluit dit is nie n PMB nie en hulle betaal niks van die chemo behandeling nie, wat daarvan as ons nie fondse gehad het nie? Nou het ons gewag vir 3 maande en daar het niks verander nie!! Die council het bepaal dat dit wel n PMB is maar nogsteeds betaal Genesis niks maar ek as n pasient/klient moet betaal!! Ek moet my maandelikse betalings maak, ek moet al die behandelings van TBH betaal en ek moet alles nou verder betaal!! Ek het n port laat insit vir die res van die behandeling want my are is beskadig maar ek moes vir dit betaal, want alhoewel ons die saak gewen het het niks verander nie en Genesis Medical het ons in n hoek want sodra ons nie betaal nie word ons ****rak gekanselleer en dan het ons niks!! Geen ander mediese fonds gaan my nou aan neem as n lid nie. Ek weet nie meer nie, ons het die saak geneem na die counsil en hulle het besluit dat dit wel n PMB is en hulle besluit is dan tog finaal of werk dit nie so nie. Hoe kan elke dokter en elke onkoloog wat na die uitslae kyk se dit is n PMB en dan kan Genesis Medical net besluit dit is nie en nou moet almal dans na hul pype en wanneer daar deur die medical council ook besluit word dit is n PMB verander nogsteeds niks. En hulle het nou besluit om n apel in te dien en dit nog langer uit te rek. My gemoed is plat, ek voel ek is n las vir my gesin, meer n problem as iets anders want die geveg gaan nou van nuuts af baklei word. Ek het 6 maande laas vir myself gekyk. Ek voel lelik en half, soos n winkel pop in n horror fliek, hare en sonder haar pruik op. Ek is moeg tot binne my siel, maar soos Hein se dit is nou groter as net ons, ons baklei nou vir die volgende persoon. Die 1 wie nie die krag het nie. Die 1 wat alleen is en ons sal saak maak. Hein het n detail lys met emails heen en weer van alles wat ek hier bo genoem het bymekaar gesit – alles van begin tot die einde. Dis vir my n nagmerrie – moet nie stress nie se almal – maar hoe anders as jy teen die stroom baklei? Ek vra hulp – help my om hier reg te maak, nie net vir my nie maar vir die volgende vrou wat deur dieselfde ding gaan en help my om Genesis aanspreeklik te maak. Hulle kan nie weg kom Hiermee nie, Weer, my naam is Vonne en ek maak saak, ek wil lewe, vir my man, my kinders en eendag se klein kinders wat nog kom, vir my ma, vir my susters en almal wat vir my omgee.
274 replies
Review Distribution
5 Star
0 (0%)
4 Star
0 (0%)
3 Star
0 (0%)
2 Star
0 (0%)
1 Star
2 (100%)