Publications
Partners
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.”
