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Updated 07 March 2017

Medical aids discriminate against psychiatric patients

South African Medical Aids are under scrutiny after the World Psychiatric Association highlighted the lack of benefits for psychiatric patients.

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A recent consensus by the World Psychiatric Association placed the spotlight on South African Medical Aids and their benefit systems. For years psychiatrists and psychologists have been speaking out about and attempting to lobby for better or at least equitable benefits for psychiatric patients, but now the discrimination against members with mental health conditions by medical aids has also attracted recent media attention.

Mental illness has carried a stigma for almost as long as it has been around. With a less than illustrious history, the treatment of mental illness has come a long way, although even today it carries a stigma. In most western countries education has helped the public to understand how mental health conditions are no different to other general health conditions and people with these conditions are no longer branded possessed and outcast from society. Though in spite of this, today there is still a negative attitude amongst most lay people, with sufferers being branded crazy, dangerous and weak-minded.

Sadly this stigma prevents many people from seeking the help they need, from receiving support from family and friends and even sometimes from receiving effective and affordable treatment.

For years even the practice of medicine for the mentally ill has carried a stigma, with Pretoria psychiatrist, Franco Colin, stating that psychiatric illness is still not even considered a general medical condition - which it is. Due to this stigma, psychiatric patients do not seem to enjoy the same rights that people with more general medical conditions do - from state funded health systems and medical aids.

The South African Society of Psychiatrists' 11th Biennial Congress, in 2000, saw the launch of the Anti-Stigma Initiative, with the full support of the World Psychiatric Association. Unfortunately though, when psychiatrists and psychologists speak out against this unfair treatment, they are not taken seriously as they are seen as having a vested financial interest in the issue.

Patients must lobby
For things to change, the pressure is going to have to come from patients themselves and the media. For the past six years the South African Depression and Anxiety Support Group, Africa's largest patient advocacy group, has been fighting this stigma, through education of the public as well as health professionals. A number of awareness campaigns have also been launched.

Due to an increasing number of calls concerning medical aids and their cover for mental illness, the Group undertook a mini survey of 10 medical aids, comparing plans that fall into the R700 - R1050 premium for the adult member category. Medical Aids included in the survey were: National Medical Plan - Comprehensive; Omnihealth, Medihelp Sentinel, Old Mutual Mars, Bonitas Elite, Medihelp Dimension, Discovery Classic Comprehensive, Medicare Chamber Nugen, Medicare Chamber Optimum and Medicare Budget.

Bonitas and National Medical Plan (NMP) had the best cover for mental illness, with NMP covering all costs for any psychiatric hospitalisation and treatment in SANCA approved rehabilitation centres, but only covering 80% of mental health services (consultations) with a R1200 limit. Bonitas has a R20 000 limit for mental health services, but any hospitalization is also included in this amount. The rest of the medical aids had even worse benefits. These benefits may not look that bad, but when compared to the cover provided for cancer or heart disease, the discrimination becomes clear.

Understandably over the last few years medical aid funders have had to tighten their belts as the market has become more competitive and the member demographics have changed, but attention should be brought to ensuring all conditions are given equal consideration. Blatant discrimination is being seen toward patients with mental illness, with some medical aids refusing to cover any hospitalisation due to suicide attempts, and others providing absolutely no cover for any substance abuse disorders. Some hospitals will not treat patients who are under the influence of any illegal substances, even if their lives are in danger.

Some medical aids expect the patient to provide 50% of the estimated costs upfront for any psychiatric hospitalisation before they will agree to cover any costs, while others penalize patients for not gaining prior authorization before being hospitalised. This is despite the fact that a psychotic episode is about as predictable as a heart attack.

While medications for heart disease are considered chronic and covered with less hesitation, psychiatric medications often require time-consuming motivations from psychiatrists and often are not on the medical aid's approved list of drugs.

The problem with this is that more and more cases are being seen of patients, who after finally finding the correct treatment for their condition and after two months are feeling better, suddenly discover that they can no longer afford the treatment. Their medical aid has run out and they are now expected to cover the remaining costs themselves, which are most often substantial. Unfortunately, in many cases, the very disorder that is costing them so much, is the reason they don't have the necessary funds available. It is easy to see how a situation like this could cause a relapse.

Sometimes medical aids encourage the substitution of cheaper generic medications for the original trade name products. Although most generics are effective, with a very narrow margin of difference, they are still different to the original product. They are sometimes slightly stronger or less potent and can have slightly different effects, unfortunately sometimes causing potentially life-threatening drug interactions and unpleasant side-effects.

Contravening the constitution
A paper presented at the recent Psychopharmacology Congress outlined how some of these policies of the medical aids could be contravening the Constitution. Section 9 of the Constitution states that no person may unfairly discriminate directly or indirectly against anyone (and this includes disability), while Section 14 of the Constitution guarantees everyone’s right not to have their privacy of communication infringed.

The National Patients’ Rights Charter, launched by the Department of Health in November 1999, states that any information concerning one’s treatment may only be disclosed with informed consent, except when required in terms of any law or an order of court. Section 27 of the Constitution guarantees everyone’s right of access to healthcare and states that no-one may be denied emergency medical treatment.

While mental health conditions like chronic depression, substance abuse disorders and schizophrenia remain shrouded in mystery and regarded with fear, and are not regarded as medical problems, just like cancer and heart disease, these patients will remain stigmatised and outcast, making recovery even harder to achieve.

For more information please contact the Depression and Anxiety Support Group on (011) 783-1474 or (011) 884-1797

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