Updated 01 August 2013

Discovery scheme torment for Joburg woman

For almost two months Beverley Smith has been in agony, and has now lost the use of her leg while her medical scheme continued to deny authorisation for a spinal operation.


A Johannesburg woman has spent more than a month in excruciating pain, waiting for spinal surgery which her medical scheme has refused to authorise until now.

Beverley Smith (58) was on holiday with her husband Basil when she started experiencing pain in her left leg, hip and knee. This quickly progressed to partial paralysis of her leg.

“Bev is a strong-headed woman, and I suppose she might have misinterpreted the initial symptoms as just a pulled back muscle. The severe pain and partial paralysis developed within a day or two, and I assume the painkillers and anti-inflammatory medication which she was taking probably “masked” the problem” said her husband Basil.

However, the real nightmare for Beverley, who is a Discovery Health Medical Scheme member, began when Discovery refused to authorise surgery, despite letters from her specialist doctors, citing the importance of the surgery.

All treatment refused

Basil said that initially Discovery refused any treatment. They claimed that she did not qualify because she had not undergone six months' ‘conservative treatment’, in compliance with the SA Spine Society Guidelines.

According to a report in The Star, Beverley’s neurosurgeon, Dr Percy Miller and an orthopaedic surgeon had both written letters of motivation to Discovery, explaining her urgent need for an interspinosal stabiliser and fixator – known as a U-device – to be inserted surgically in her spine, and a decompression. But Discovery refused the authorisation.

This went on for weeks and by the middle of July, Beverley’s condition had worsened to the point where she was mostly bed-ridden and had lost the use of her left leg. She was also in constant , agonising pain.

Following the report in The Star and subsequent media coverage however, it appears that Discovery has overturned its decision.

However, the Smiths remain in the dark about where to go from here, as it appears Discovery is not keeping them in the loop.

“Discovery is not communicating directly with me. All the communication is sketchy, and in my opinion they are not 100% specific, other than that they still claim that I am not actually covered for the specific condition, and that it is not a PMB [Prescribed Minimum Benefits] condition."

“As far as I know they have contacted one of our doctors to advise that he may only operate to remove the “obstruction” but not insert the interspinal device – but he apparently declined to do half a job.”

What Discovery says

In a statement received from Discovery, Dr Jonathan Broomberg (CEO Discovery Health Medical Scheme) said that the scheme “provides cover for spinal surgery according to the benefits of a member’s specific plan type. As spinal surgery carries significant risks and should only be done where appropriate, these benefits are also subject to defined clinical guidelines, which are developed in consultation with leading spinal surgeons in South Africa. This ensures that the guidelines take into account the latest available published evidence and the best available local and international expertise, including the risks and benefits for patients from this type of surgery.”

With regard to the Smith’s case he said, “The initial request for funding for the spinal surgery using the interspinous device was declined, as Mrs Smith did not meet the criteria as per the Spine Society Guidelines. This does not imply that any spinal surgery was declined, but only the use of this specific device.

Subsequently Mrs Smith consulted a new doctor to obtain a second opinion, and late last week, Discovery Health received further detailed clinical information. This updated information was submitted to the SA Spine Society, which confirmed that the patient will benefit from spinal surgery in terms of the Society Guidelines.

This was not the case based on the prior information. Based on this updated information, we have indicated to the member that the spinal surgery will be authorised immediately.”


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