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Bev Baxter

On the 20 April my life and that of my family was thrown literally on its head. After feeling a little off colour I decided to make an appointment with a Physician as visits to my local GP had not found the cause of my chest pains and intermittent nausea the result of this visit saw me at the age of 43 being diagnosed with Breast Cancer, Stage 4 with bone metastases (Basically the primary source of cancer was my right breast and it had spread to all my long bones).

I had a choice to either fight or allow Cancer to be the victor. The latter was not an option as I have so much to fight for, a wonderful husband to whom I’ve been married for 21 years and two beautiful teenagers aged 13 and 15. I chose at the onset of my diagnosis to get my family and friends together and share everything that was happening with my health status and treatment on a day to day basis via sms. I did not want anyone to be afraid to ask me how I was or to be nervous to ask questions regarding the progress of my chemotherapy treatment.

It was in sharing my daily updates on my treatment that I be-came astounded as to how many women in my family, friends and colleagues were in what I called a state of Disempowerment. The lack of knowledge shown by my very own network has made me even more determined that my fight with Cancer will not be in vain. I have make it my personal undertaking to ensure that I will empower all within my family and network with as much knowledge as possible .I believe that knowledge is power and armed with this youre able to make an educated decision where the well being of yourself and that of your families are concerned.

When I took myself off to see a physician, I was convinced the diagnosis would be a stomach ulcer and still joked that I wanted to go first as I wasn’t swallowing a scope that someone had had before me. Imagine my shock when I received the call on the Monday to say my blood tests were back and did not look good. I was advised that a bone marrow biopsy was urgently required and they would be testing anaemia to leukaemia. Here started my long journey with my medical aid. I phoned for authorisation only to be told that a bone marrow biopsy was a day theatre procedure and as such came out of my day to day funds. My day to day funds were already depleted due to dentistry I had required. Then onto the labs to ask what this bone marrow Biopsy would cost? R 11 000 I was told, cash up front before the procedure as if I chose to be invoiced via my medical aid it would end up costing more? Had I had gap cover this wouldn’t have posed a problem, but I didn’t. The problem wasn’t that we weren’t aware of Gap cover but just that we were waiting on our medical advisor who didnt have a sense of urgency on the matter. You see agents dont make much commission on Gap cover. So now I who needed and still needs gap cover the most have nothing, but the rest of my family is covered.

The Biopsy revealed cancer but I was misdiagnosed. I was informed on the wed evening that I had leukaemia only to be told the following morning that my cells were disguised and that I had cancer but they now needed to start the x-ray process of all body organs to determine which organ had been affected. At this time my red cell count HB was down to 4 and platlets down to 17000 and I was already receiving the first of my three blood Transfusions. It was at this stage that my husband was dealing with my medical aid matters as I was too ill and basically a haemophiliac due to low bloods. I started my first chemo in hospital as they could not afford for me to start bleeding as with a low platlet count of 17000, I would bleed out.

Chemo progresses at a reduced dose until I reached the magic number of 55 000 platlets, now I could have the magic PET scan. This PET scan would reveal my total disease state eventually so a treatment protocol could be determined to get me on the road to recovery. The PET was applied for and approved by my medical aid but my husband was advised that their was a co payment of R 2750.This is where knowledge and reading the fine print of your medical aid comes into play. My hubbby Greg just wanted to get me well and was in no emotional state to question this co payment. Had we read our policy, we would have read that our medical aid required we use a DSP (designated Service provider), however our medical aid didn’t have a signed agreement with a DSP in Durban for PET scans and as such the law as laid down by the medical council of schemes states that the medical aid or provider should have paid for the PET Scan in full and we should not have been made to pay this co payment.

We are all very glib when it comes to our medical aids. We are employed by a company which dictates pretty much which medical aid we belong to, the only real choice we have is the option or level we choose which is pretty much dictated by what we can afford. The reality is that we seldom investigate to the nth degree what exactly we are covered for. We know the basics ie R x cover for day to day and the rest we meander through glibly. It is imperative that you understand your legal rights in respect of medical cover. Medical aids have started many cost cutting measures and often at the expense of its members and we are only made aware of these when we are faced with either a dreaded disease of chronic diagnosis not the time to find how little cover you actually have.

As per the council of medical schemes in South Africa all medical aids have to cover 27 Chronic Conditions in full without any co-payments. There are however another 270 conditions that are also covered under this PMB umbrella of which Cancer is one of those. What often happens is that if you’re diagnosed with a heart, diabetes etc you’re prescribed medication by your specialist. You are then informed by your medical aid that they will only cover the generic and should you want the original then you will have to pay the shortfall between the two. However you may be one of those who’s non-responsive to generics in which case your medical practitioner is then required to assist in writing a motivation to substantiate why you cannot take the generic and your medical based on sound medical evidence is obliged to supply the original drug at no additional cost.

Then medical aids throw another acronym at us DSPS- designated services providers. Who are these people? Well as a way of squeezing the best price out of their supplier ie GP"s , specialists, hospital groups, they negotiate a flat rate for all their members with said gp's, hospitals guaranteeing volume versus reduced charges. Again if you don’t make yourself offay with who your dsps are and make use of them you find yourself paying the shortfalls again and in the case of hospital admission you will be charged a lump sum upfront before even being admitted and then as costs have been negotiated you are left with huge shortfalls.

Then comes GAP cover - A number of medical aids don’t even cover this in their presentations as the agents don’t get commission on these sales hence why worry to promote. GAP cover is a separate insurance policy over and above your medical aid contribution which will cost you in the region of R 100 per family. This is not the same as the self payment GAP. The GAP cover only applies for in hospital cover and basically covers any shortfalls incurred whilst receiving treatment in hospital ie the difference between what the hospital and or Dr charges.


I have travelled the Cancer path for 19 months so far and am still fighting recurring bone metastisies, having had 21 chemo treatments IV, a bilateral mastectomy, 25 Radiation sessions and am now on oral chemo twice daily with hormone and bone treatment every 3 months. I am one of the fortunate few who has stood on the other side of the fence and been a supplier to medical aids and thus when I was diagnosed in April only to be told in September of 2010 that my R 200 000 for cancer treatment was depleted and I would now have to make a 20 % co payment on all treatment going forward I was blown away. Why a co-payment? I have cancer. This is a PMB - prescribed minimum benefit? My medical aid as per the Medical Schemes Council stated that my medical aid was obliged to pay for all my treatment? Wrong again. My medical aid only had to pay for my treatment in full if the treatment prescribed by my dr fell within TIER 1 protocol for my disease state as decided upon by the SAOC. My disease state was declared a TIER 2 by my medical so I was to pay the 20% co payment. If you’re a patient without family or in a good financial situation with policys etc this co-payment can be financially debilitating for a family. This saw us moving up to a higher medical aid tier where I would have R 400 000 in the forthcoming year. The worst is that a treatment year for a cancer patient runs from the date of diagnosis, in my case April 15 2010 to April 14 2011.With funds depleted by September we had to co-pay for 5 months until my new medical cover kicked in.

I tried in vain to communicate with my medical aid but it’s the most frustrating thing ever as you are never given all the information you require. You need to ensure you understand you disease and its management better than anyone else or be at the mercy of your provider. I am medically boarded at 43 yrs and I thank God that although the rest of my body is taking a hammering I am able to still assist patients who are battling to get funds to literally stay alive. I have in the past year (and still continue to do so) made myself available depending on my heath status to Cancer patients who are battling to get cancer drugs to stay alive but due to lack of medical aid knowledge do not know how or where to turn to get the authorisations they so desperately need. Knowledge is king and as long as I breathe I will continue to educate through whatever medium available to me to make patients aware of what their rights are and how to access the medical care they so desperately need but are often denied due to lack of funds and knowledge.

 

 

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