In what Business Day calls a scathing and precedent-setting ruling against Discovery Health Medical Scheme, the industry regulator has opened the door for consumers to force the industry to pay for treatment not available in state hospitals.

The Council for Medical Schemes’ (CMS’) ruling follows a case by an eye-disease glaucoma patient, who took the scheme on after it refused to pay for an implant of a medicated device called a Xen stent to lower eye pressure as recommended by a specialist.

The scheme – which would have paid for a treatment more than two times what the device would have cost – argued that clinical evidence on the effectiveness of the stent was weak, and that it was legally entitled to refuse payment for it as it was not offered in state hospitals.

‘It is mind-boggling that Discovery would be willing to fund the inappropriate treatment for R20 000 and refuse to fund an effective, affordable and cost-effective treatment for R9 000. This kind of decision-making is viewed as irrational,’ Judge Bernard Ngoepe, head of the CMS final appeals board, said in a ruling.

Ngoepe said that the state did not solely rely on affordability and effectiveness when deciding whether to introduce a new treatment.

‘State hospitals can be affected by budgetary constraints, delayed bureaucratic tendering and procurement processes, skills shortages, training priorities, administrative challenges,’ he said.

Full Business Day report