[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...


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