Medical aid scheme Medihelp has been entangled in a legal battle for more than two years with a Gauteng mother over treatment for her son’s rare inherited genetic condition, with the scheme digging in its heels and refusing to cover costs for the vital medication.
Now Medihelp has lodged an application for the court to reconsider a 2022 High Court order for it to pay for the drug, pending a complaint to the Council for Medical Schemes (CMS).
Zachary de Wet, who is five, suffers from Hunter syndrome, which causes a build-up of sugar, resulting in organ and tissue damage as well as developmental problems.
The only registered treatment is an enzyme replacement therapy called Elaprase, but Medihelp refused to pay for this – around R300 000 a month – on the basis that it was not registered as a prescribed minimum benefit and that his plan did not cover the treatment.
News24 reports that in 2022, Zachary's mother, Michaney de Wet, went to court and got an order directing Medihelp to cover the costs of the Elaprase, pending a complaint to the CMS.
But three months later, the CMS found against her and Medihelp stopped paying. De Wet subsequently lodged an appeal and returned to court where she got another order which confirmed the previous ruling stood until any potential appeals had been finalised.
Medihelp was granted leave to appeal the second order, and its application was on the roll for hearing last week.
In the appeal, Medihelp’s position was essentially that the first order “was satisfied and came to an end” when De Wet lodged her complaint with the CMS.
It wound up being removed from the roll, however, on the basis that Medihelp has now also launched an application to have the first order reconsidered, in which it has now changed its stance.
Judge Cornelius van der Westhuizen said the reconsideration application rendered the appeal “dead”.
De Wet’s advocate, Mohammed Cajee, argued the appeal should rather be dismissed or that the court should also make an order that, pending the outcome of the reconsideration application, Medihelp was obliged to cover the cost of the treatment.
Otherwise, he said, with the appeal still pending, the second order was automatically suspended and they were left in the lurch.
As it stood, he said, Medihelp was not paying for the treatment, which was being covered by a private donor.
The court declined Cajee’s requests, saying his clients could approach the courts for an enforcement order in the meantime, if necessary.
See more from MedicalBrief archives:
CMS faces court action after refusal to pay child’s rare disease treatment
Judge orders medical aid to pay for boy’s expensive medication
Ill child’s parents sue medical aid over drug for rare disease