Mother locks horns with medical aid scheme
Two years after Medihelp was slapped with an order from the Gauteng High Court (Pretoria) forcing it to cover the cost of treatment for an Alberton boy with a rare inherited genetic condition, the medical aid scheme is still fighting to avoid having to pay up and now wants the court to reconsider its decision.
News24 reports that Zachary de Wet (5) suffers from Hunter syndrome, which causes a build-up of sugar, resulting in organ and tissue damage as well as developmental problems.
The only registered treatment for the condition is an enzyme replacement therapy called Elaprase.
However, Medihelp refused to cover the cost – about R300 000 a month. This on the basis that it was not registered as a prescribed minimum benefit and that his plan did not cover the treatment.
In 2022, Zachary's mother, Michaney de Wet, went to court and got an order directing Medihelp to pay for the treatment pending a complaint to the Council for Medical Schemes (CMS).
Three months later, the CMS found against her and Medihelp stopped paying. She returned to court and got another order which confirmed the previous ruling stood until any potential appeals had been finalised.
News24 reports that Medihelp was granted leave to appeal the second order.
In the appeal, News24 notes that Medihelp's position was essentially that the first order ‘was satisfied and came to an end’ when De Wet lodged her complaint with the CMS.
Judge Cornelius van der Westhuizen said the reconsideration application rendered the appeal ‘dead’.
Advocate Mohammed Cajee for De Wet, argued the appeal should rather be dismissed or that the court should also make an order that, pending the outcome of the reconsideration application, Medihelp was obliged to cover the cost of the treatment.
‘As long as the appeal is removed from the roll, it stays alive and it suspends the operation of the (second) order. That can't be because now it is common cause the order continues and can be implemented further,’ he said.
The court declined Cajee's requests, saying his clients could approach the courts for an enforcement order in the interim, if necessary.
Article disclaimer: While we have made every effort to ensure the accuracy of this article, it is not intended to provide final legal advice as facts and situations will differ from case to case, and therefore specific legal advice should be sought with a lawyer.
