Understand your medical aid benefits – Breast cancer and mastectomies

breast cancer and mastectomy

The diagnosis of breast cancer can be a physical, emotional and psychological roller coaster, as one is just never prepared for it.

Many aspects of the disease can cause tremendous stress. The treatment with a mastectomy is one such example.

Having a mastectomy

A mastectomy can range from removing the cancer and some nearby breast tissue, to removing the entire breast, skin, nipple and underarm lymph nodes. It can involve one breast or both breasts.

During this time women typically experience emotions such as shock, fear, anger and disbelief. Many are concerned about whether they’re making the right decision. It is also common for depression to set in – even before the procedure. Support from close family and friends is very important during this time.

Financial implications

Often times the financial implications in respect of the treatment of breast cancer can bring other challenges. This is where the saying “hindsight is perfect sight” may take on a complete new meaning.

You may be fortunate enough to have sufficient private funds in place to cover all your medical expenses. You may also have long-term insurance policies for dread disease, or you may have medical scheme cover that will assist in the funding of your treatment.

Medical aid funding options

It is very important to understand how your medical scheme will fund the cost of your breast cancer treatment. All medical schemes in South Africa define in and out-of-hospital sub-limits for such treatment in their registered rules. Sub-limits are usually applicable when members are treated in private facilities. The cost of cancer treatment as a PMB by / at Designated Service Providers (DSPs), or the state, will usually be unlimited, provided that specific clinical protocols and criteria are met.

Medical scheme rules and clinical protocols

Despite the fact that cancer treatment may be a PMB, when a member is treated in a private facility, it is important to understand that your medical scheme funding for such treatment will always be based on the registered rules and clinical protocols of your scheme. Funding for certain treatment protocols, or certain drugs – even if it is based on the recommendation of your treating doctor – may only be applicable if the clinical protocols as per your medical scheme rules are met.

Will a bilateral mastectomy be funded?

From time to time doctors may recommend a double (bilateral) mastectomy and reconstruction where in fact only one breast has cancer. The majority of medical scheme benefit options in South Africa may however only make provision for funding of the affected breast.

In certain instances, a bilateral mastectomy and reconstruction may be considered, provided that specific clinical criteria are met and the surgical intervention is the accepted standard level of care for PMBs. However, when the clinical criteria are not met, a medical scheme will not fund such a bilateral procedure.  The unaffected breast would be excluded from any medical scheme funding benefits due to the absence of a qualifying medical / illness condition in the healthy breast. Under these circumstances the mastectomy and reconstruction of the healthy breast will be for your own account.

Understand your cover

People often think that the treatment of cancer will be covered in full by their medical aids. That may however not be the case. Speak to your medical scheme about your funding benefits for cancer and find out exactly how they will cover the cost of your treatment.

The Content on this site is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Image:  Freepik

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