Government medical scheme, Gems, has responded to allegations that it refused to pay for treatment for one of their clients who has stage four cancer.
Chief Operating Officer at Gems, Dr Stan Moloabi says the cancer treatment drug, Keytruda, which Dr Sipho Bvuma's oncologist recommended is not registered for specific cancer that Bvuma suffers from.
He says the medical scheme rules do not allow for funding of drugs that are not registered for specific ailments.
In this instance, there were two panels of experts who had to consider this request and both are panels of oncologists and they came to the conclusion that it will not be appropriate to fund this said treatment.— Dr Stan Moloabi, Chief Operating Officer at Gems
This is the second time that Gems denies payment of treatment for Bvuma. He says he initially took them to court and the court ruled in his favour.
He has approached the courts for the second time now for the funding of the drug Keytruda which he believes will prolong his life and move him into remission stage.
There are clinical decisions that are taken by the doctors that are treating and we need to separate them from funding decisions. This is a difficult concept but that is how funding is done.— Dr Stan Moloabi, Chief Operating Officer at Gems
The funding decision is based on the scheme rules...— Dr Stan Moloabi, Chief Operating Officer at Gems
If medication is not proven to work in that category, then Gems will not be acting responsibly to be funding something that is ultimately not going to work.— Dr Stan Moloabi, Chief Operating Officer at Gems
Moloabi says the latest update sees the court setting aside Bvuma's application to have Keytruda administered.
He says Gems panel of experts will again relook at the funding of Keytruda and make a decision because this is a "matter of life and death".
The lawyer representing Dr Sipho Bvuma, Linda Skhosana, denies that the court set aside the matter. He says that the court has referred the matter to the Council for Medical Schemes Appeal Board and if they are not satisfied with the outcome they should return to court.
To hear the rest of the conversation, listen below: