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Does your medical aid have you covered?
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Hi there!
My name is Alwyn Uys. I'm a para-athlete from South Africa. In 2014, I was involved in a car accident that changed my life. Since then, I have taken myself through many ultra-endurance challenges, which was only made possible through determination, discipline and a strong belief in myself.
As a para-athlete you have to perform at your best every day. However, I have found it difficult as my medical aid has short paid against my claims for intermittent catheters. As a result, I was purchasing many of my catheters out of my own pocket. This became an annoyance, which caused a lot of financial stress, until I chose to challenge my medical aid.
With this letter, I want to share my story and encourage you to take responsibility for your own health by challenging your medical aid if your experience is similar to mine. We need to take a stand as members to ensure clinical standards are followed; that we have access to the right treatment.
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Medical aid’s decisions: Can they be challenged?
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The short answer is – yes. Remember, you are the customer. If you have a prescribed minimum benefit (PMB) condition, your medical aid is obliged to deliver certain minimum health services, regardless of the benefit option you have selected.
If you have difficulties in emptying your bladder, you have a PMB condition, which means that the treatment should be funded in full by your medical aid.
My medical aid didn’t fund my intermittent catheters in full although my health, wellbeing and performance as an athlete completely depends on them. Previously, I used a reusable catheter to empty my bladder and, after many infections, my doctor suggested a sterile, hydrophilic-coated intermittent catheter.
When I first claimed for these new catheters, my medical aid only funded 30 catheters out of the 180 catheters that I require per month. However, after much argumentation and several interactions, my medical aid now provides 180 intermittent catheters, funded in full, per month.
To be able to see the result my efforts and hard work show, really gives me the motivation to continue the fight for my health.
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The truth is you’re in the driver’s seat when it comes to your own health
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I am not an expert in this field but, based on my own experience, I want to give you some advice on how to advocate for your own health and, if needed, challenge your medical aid’s decision.
- Advocate for your own health: First, remember that you need to take the responsibility of your own health. Often, you know what’s best for your health and wellbeing and you need to make sure your doctor and medical aid are on your side.
- Understand your rights as a member: It is critical to understand your medical aid’s authorisation as well as your rights to PMB healthcare services. For example, for what does your medical aid approve funding and on what background? Although it can be complicated and time consuming to research, you need to understand this before you contact your medical aid.
- Seek advice from others: If you don’t know exactly for what to look, seek advice and support from peers, your doctor and patient associations such as the QuadPara Association of South Africa (QASA). They are often more than willing to help you with guidance and providing you with the right documents. Some medical suppliers even offer you case management assistance.
- Take action: Just do it. Write down your argument, let a second pair of eyes read through it and contact your medical aid. Also, be aware that if your medical aid isn’t responsive, you can contact the Council of Medical Schemes (CMS). They can help you file a complaint.
- Be patient and don’t give up: Lastly, keep in mind that you may not get the result you’re hoping for on the first try – like in my case for example. It doesn’t mean that you won’t get there, but it might require more than one attempt to get to an acceptable result.
We are advocates fighting for our own health and wellbeing, as well as for others, by getting the right to adequate treatment. So, don’t give in. We’re in this together.
Sincerely,
Alwyn Uys
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