CMS’ precedent setting ruling against Discovery’s ‘irrational decision-making’ - MedicalBrief 290 - 20 January 2020

CMS’ precedent setting ruling against Discovery’s ‘irrational decision-making’ - MedicalBrief 290 - 20 January 2020

MedicalBrief 290 - 20 January 2020

"In “a scathing and precedent-setting ruling” against Discovery Health Medical Scheme, the Council for Medical Schemes (CMS) may open the door to force schemes to pay for treatment not available in state hospitals, reports Business Day. A more cautious analysis in Business Insider says that while the ruling does not arbitrarily expand benefit coverage, it “prevents the restriction of benefits on arbitrary criteria – such as a crude reference to practice in public services”.

The CMS ruling follows a case by an eye-disease glaucoma patient, who took on the scheme, which is administered by financial services group Discovery’s health insurance arm, after it refused to pay for an implant of a medicated device called a Xen stent to lower eye pressure as recommended by a specialist.

The report says the CMS’s ruling also puts the spotlight on the interpretation of regulations under prescribed minimum benefits, which requires medical aids to pay in full the treatment of a long list of diseases but has not been updated in 20 years. The list, which includes pregnancy, 270 diseases and 26 chronic conditions, was supposed to be evaluated by the regulator every two years from 2000, taking into account new treatments and costs, but the regulator is undertaking its first review of the list. It has been a source of disputes as there is no limit on how much medical aids must spend."

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https://www.medicalbrief.co.za/archives/cms-precedent-setting-ruling-against-discoverys-irrational-decision-making/