Don’t want recommended treatment- Important!

Non- compliance with protocols and recommended treatment by members

Every once in a while an important note comes up that is not really discussed or made “public” by schemes or companies. This IS one of those.

The link to the Council Circular will be put at the bottom of this post.

What is this all about and why am I making a fuss?

My Story: I had a previous partner who contracted cancer. She was insistant that she would not be following the normal procedures (chemo, radiation, etc.) as she wanted to utilise alternative techniques and herbal remedies and so on.

As a result of this, the medical scheme would not pay for certain treatments (there would even have been a life policy issue – thankfully, the life company involved was forward thinking).

So, in essence the element of free choice is taken away from a member that is in a life threatening situation, who chooses to do things in another way and in the same way tries to maintain some dignity.- this leads me to this Circular issued by the Council.

Extracts from this Council Circular:

Previously the Council for Medical Schemes has informed schemes that non- compliance with specific clinical protocols and recommended treatments by members may not result in the non- payment of claims.

However, a co-payment could be applied. This would need to be specified in the Schemes Rules.

Where a member has refused Hospital treatment, the scheme is not liable to fund claims… whether the condition was a PMB or not.

The Council has investigated a query from an administrator, which has lead to a look at the principle of “informed consent”.

The concept of “informed consent”does not only apply to treatment agreement and the cost of such treatment, but also to the refusal of treatment, or the choice of alternative treatments. Mentally capable members and beneficiaries¬† have the right to refuse treatment, even when the refusal may result in disability or death. The principle of informed consent would be pointless if it does not protect the member’s rights to refuse a proposed course of treatment in or out of hospital at any time.

In view of the above, the CRC came to the conclusion that refusal of hospital treatment is a form of non- compliance and needs to be managed in accordance with best ethical practices, the same manner as non- compliance with any other medical treatment or protocol.

The CRC has reviewed the previous decision where medical schemes were not obliged to pay for the refusal of hospital treatment and withdraws such decision. Subsequently, all claims with regards to the payment of PMB in cases where a member refuses hospital treatment must be funded in accordance with Regulation 8, taking into account the provisions specified in Regulations 8 (4) and (5). Claims with regards to the payment of non- PMB in instances where a member refuses hospital treatment must be funded in accordance with the medical scheme rules.

There is also specific mention  of cotinine tests , where a member is positively tested with regards to COPD.

You can download the Council Circular here: circular75of2016pmbs non compliance


Don’t want recommended treatment- Important! was last modified: February 14th, 2017 by Kenny Williamson

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