This article examines the extent of medical schemes’ funding obligations for treatable vs non-treatable cancers.
From a medical perspective, doctors often argue that most forms of cancer are “treatable”, however, medical schemes have no obligation to fund the treatment of non-PMB cancers other than as provided in a member’s selected benefit option.
Are medical schemes obliged to pay for the treatment of all cancers?
No. Schemes are only legally obliged to fund PMB (Prescribed Minimum Benefit) conditions, and then only to the extent set out in the Medical Schemes Act (MSA). For non-PMB cancers, a medical scheme’s liability is limited to the benefits offered by the member’s selected benefit option.
Medical schemes in South Africa are statutory bodies that reimburse claims in accordance with the MSA and the scheme’s rules. Schemes do not assume open-ended liability; rather, they are legally bound to honour the contract entered with members, which in turn is framed by the MSA.
Not all medical aid plans cover the full cost of cancer treatment
To illustrate this in practice, consider the case of Mrs X, who was a member of Genesis’ MED-100 entry-level hospital plan, under which out-of-hospital oncology benefits are limited to PMBs in state hospitals. When Mrs X was diagnosed with cancer in her right breast that had spread to adjacent organs, Genesis reimbursed all qualifying in-hospital claims related to her mastectomy, in line with her plan’s benefits.
Later, Mrs X applied for funding for chemotherapy and the biologic drug Herceptin on an out-of-hospital basis. The Scheme declined her request, noting that she had elected a lower contribution option that did not cover non-PMB oncology treatment. Because her illness did not qualify as a PMB, the Scheme was under no legal obligation to fund further treatment beyond what her benefit option allowed.
What does the Medical Schemes Act say about the treatment of PMBs?
The dispute in this instance was not about clinical efficacy, but about statutory interpretation. Regulation 7 of the MSA defines PMBs as the benefits listed in Annexure A of the Regulations. These consist of Diagnosis and Treatment Pairs (DTPs), which require both a qualifying diagnosis and the prescribed treatment. Importantly, the law is explicit that a PMB is not established by diagnosis alone; the condition must also meet the prescribed criteria for treatment that is limited by regulation.
Definition of “treatable” breast cancer
Annexure A to the Regulations lists “Cancer of breast – treatable” under DTP 950J, falling within the category “Skin and Breast.” The crucial element here is the term “treatable,” which is given a strict legal meaning through Explanatory Note 3 to the Regulations. According to this note, a solid organ malignant tumour will only be regarded as treatable where:
- It involves only the organ of origin, with no spread to adjacent organs
- There is no evidence of distant metastasis
- It has not caused irreversible or irreparable damage to the organ of origin or another vital organ
- OR if none of the above applies, the cancer may still qualify if there is a proven five-year survival rate of greater than 10% for the relevant therapy.
The Regulations further clarify that if any one of conditions (i) to (iii) is present – spread to adjacent organs, distant metastasis, or irreparable organ damage – then the cancer is not regarded as treatable as prescribed by law. In such circumstances, condition (iv) does not apply.
When breast cancer is not a PMB
In Mrs X’s case, the cancer had spread to adjacent organs and had caused irreversible damage to the breast, which was surgically removed. As a result, her cancer did not fall within the statutory definition of a treatable breast cancer, and thus it was not a PMB.
Had Mrs X been treated at a public hospital in accordance with the prescribed regulations, section 29(1)(p) of the MSA would have required full reimbursement of qualifying PMB claims. But, because her cancer was not classified as treatable in law, even that entitlement did not arise.
Not all medical aid benefit options offer equal benefits
Genesis therefore had no legal obligation to fund her out-of-hospital cancer treatment. The Scheme’s liability was strictly limited to the benefits available under her benefit option. Mrs X voluntarily elected membership of a lower contribution option but she expected the benefits available to other members who paid a much higher contribution.
Author: Elmarie Jensen
