[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.

RELATED: Dischem answers plea to assist Johannesburg twins with incurable disease

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...


Recommended

by NEWSROOM AI
Read More
Emergency services working around the clock to attend to flood-hit areas

Emergency services working around the clock to attend to flood-hit areas

Tshwane Emergency Services spokesperson Charles Mabaso says the SANDF is assisting in rescue operations.

[LISTEN] Tributes continue to pour in for ANC stalwart Ben Turok

[LISTEN] Tributes continue to pour in for ANC stalwart Ben Turok

Former president Kgalema Motlanthe says Turok was the very embodiment of uprightness and ethical conduct.

Rescue missions underway in flooded Centurion Lake Hotel

Rescue missions underway in flooded Centurion Lake Hotel

Eyewitness News reporter Kgomotso Modise gives updates from Centurion on the floods and traffic flow.

Rainy weather to persist overnight

Rainy weather to persist overnight

Forecaster Kgoloselo Mahlangu gives the details.

Families identify bodies of Tau Lekoa mineworkers

Families identify bodies of Tau Lekoa mineworkers

Four miners died at shaft number 10 following a rockfall caused by tremor on Friday.

Dischem answers plea to assist Johannesburg twins with incurable disease

Dischem answers plea to assist Johannesburg twins with incurable disease

The eight-year-old boys diagnosed with hollow visceral myopathy have had to survive on a special formula called Neocate Junior.

Popular articles
[WATCH] Fikile Mbalula's funny interview has social media in stitches

[WATCH] Fikile Mbalula's funny interview has social media in stitches

Khabazela shares tweets and Facebook posts that have gone viral.

 Eskom buys fine coal that looks like baby powder when wet, says expert Ted Blom

Eskom buys fine coal that looks like baby powder when wet, says expert Ted Blom

Energy analyst Ted Blom weighs in on the energy crisis in South Africa as load shedding stage 2 is implemented.

SA's Zozibini Tunzi simply the best, crowned Miss Universe 2019

SA's Zozibini Tunzi simply the best, crowned Miss Universe 2019

The 26-year-old is the third South African to be crowned Miss Universe and has made the country proud.

Want to start a small business? Lessons from a successful serial entrepreneur...

Want to start a small business? Lessons from a successful serial entrepreneur...

The Money Show’s Bruce Whitfield interviews Nic Haralambous, founder (at the cost of R5000!) of funky sock company Nic Harry.

Considering emigration? Financial planner discusses the affordability of leaving

Considering emigration? Financial planner discusses the affordability of leaving

Can you afford to leave South Africa? Certified Financial Planner (CFP) Barry O'Mahony on what to consider before deciding.

'SAA’s collapse plays nicely into hands of a politically constrained Ramaphosa'

'SAA’s collapse plays nicely into hands of a politically constrained Ramaphosa'

After dithering for fear of spending political capital, SAA is now out of the President’s hands, says Pieter du Toit (News24).

There is no Ubuntu in how Khanya Cekeshe has been treated - Thuli Madonsela

There is no Ubuntu in how Khanya Cekeshe has been treated - Thuli Madonsela

Former public protector says the eight-year sentence was too harsh and it shouldn't matter that he was not a Wits student.

‘South Africans are getting poorer and poorer because of politics’

‘South Africans are getting poorer and poorer because of politics’

SAA is a classic example, says Isaah Mhlanga, Chief Economist at Alexander Forbes Investments.

How to make your first R1 million (after that it just becomes so much easier)

How to make your first R1 million (after that it just becomes so much easier)

Rich. Wealthy. Financially free... Call it what you will; the first million is how you get there. Warren Ingram on his book...