An ongoing struggle with Discovery Health – relating to its stance on covering some of his cancer treatment costs – is frustrating Oscar Chalupsky (62), the former world canoe champion who has been fighting bone marrow cancer since 2019.
Chalupsky, who this week underwent numerous medical tests in a hospital in China (at this own cost) to determine whether highly specialised CAR-T treatment could extend his life, has been locked in battle with Discovery over whether the medical aid should fully cover one of his other treatments as a prescribed minimum benefit treatment.
News24 reports that the Council for Medical Schemes (CMS) has already ruled in his favour twice, but Discovery Health is now appealing the ruling again, said Chalupsky.
“For Discovery, these legal costs are peanuts, but for me, they’re a lot of money. And the reaction on social media shows that most people are simply giving up, because Discovery’s pockets are deep enough.”
He is fortunate in that he has people from all over the world helping support him financially, he added. “So this legal battle is for everyone else, not for me, and that’s the most important thing.”
Comfort Maluleke, Chalupsky’s case manager at the NPO Campaigning for Cancer, said the multiple myeloma with which Chalupsky has been diagnosed is an oncological condition classified as a prescribed minimum benefit (PMB) condition under the Medical Schemes Act.
He was diagnosed with this aggressive, incurable cancer in November 2019, when a tumour was discovered on his spine, and has since undergone radiation, induction therapy, chemotherapy and a stem cell transplant.
He also went to Germany for an expensive consultation to determine whether he could go on BCMA CAR-T cell therapy, which can cost up to R8m. But his condition is too advanced for that.
After several tests at the Ruijin Hospital in Shanghai, he will hear whether he qualifies for GPRC5D CAR-T cell therapy, which could potentially extend his life “by one to three years” as a last-line treatment.
Limits for prescription
Maluleke said because of the aggressive and recurrent nature of his condition, Chalupsky’s doctor prescribed Daratumumab in 2023.
“Discovery approved the prescription but required a co-payment and refused to fully fund the treatment, citing Chalupsky’s plan limits, and further arguing that Daratumumab was not considered a PMB level of care.
“Rather than fully funding the Daratumumab as a treatment for a PMB condition, the scheme covered half of the cost ex gratia – pending Chalupsky’s upgrade to their top plan – and attempted to force the other half on him.”
Aggrieved by this, Chalupsky filed a complaint with the CMS registrar in January last year, arguing that Discovery should fully fund his prescribed treatment in accordance with the provisions of the Medical Schemes Act.
“Two months later, the registrar ruled in his favour and ordered the scheme to fund the Daratumumab in full, without co-payment or penalty.
The scheme then appealed this initial ruling to the appeal committee. The parties disagreed on whether Daratumumab was a PMB-level treatment and whether it should be fully funded.
Discovery argued that Daratumumab was not PMB level of care and that there was no evidence that Daratumumab provided better clinical benefit.
The scheme further argued that “as a funder, it must balance clinical appropriateness with financial feasibility”.
The appeal committee then considered submissions from Chalupsky’s specialist physician, who noted improved clinical outcomes with Daratumumab, including improved blood counts (eliminating the need for blood transfusions) and reduced tumour markers.
The appeal committee ultimately found that the scheme had not provided any evidence to suggest that Daratumumab did not constitute PMB care.
As a result, the appeal committee found in April this year that Daratumumab should be fully funded by the scheme as the appropriate PMB level of care.
The appeal was accordingly dismissed, the registrar’s ruling upheld and the scheme was ordered to pay Chalupsky’s bill in full.
But despite the decision of both the registrar and the appeal committee in Chalupsky’s favour, the scheme has now appealed to the CMS Appeals Board for a second time. It will be heard next year.
Inaccurate and unfortunate
Discovery Health said Chalupsky’s treatment with Daratumumab was approved in October 2023.
“From October 2023 to May 2024, he experienced no financial shortfall for this treatment, apart from a 25% co-payment (R18 500) in December 2023 when he was on a lower plan type. Discovery funded 75% of the cost of Daratumumab, with the remaining 25% funded by a third-party co-payment support programme.”
The latter refers to “financial assistance offered by an entity other than the patient or healthcare provider to help cover a patient’s additional costs”.
“The funds are provided by pharmaceutical companies and managed by a third-party entity to cover shortfalls related to their respective medicines,” said Discovery Health.
In total, the scheme funded R1m for the member’s Daratumumab treatment until May 2024. Since then, there have been no claims for Daratumumab.
“In addition, the scheme has also funded R2m since his first diagnosis for other cancer-related treatments, including specialised drugs not registered in South Africa. His inference that the scheme refused funding for his treatment is therefore inaccurate and unfortunate.”
Discovery and its clinical advisers are content to say that the treatment does not constitute PMB level of care.
Chalupsky said if it were not for Campaigning for Cancer, which assists patients who have been denied or given limited access to treatment, he would not have known better. He said he had already paid more than R300 000 in co-payments.
“I know it’s a precedent that Discovery Health wants to set, but I don’t understand why, when you keep losing a case, you don’t try to see what else you can do. It costs Discovery a lot of money to fight this.”
It seems as if this is happening to a lot of other people, too, he added. “And that’s the main reason I fight so hard.”
See more from MedicalBrief archives:
Consumers shoulder burden of medical aid schemes fraud
Cancer costs thwart treatment for SA patients
Discovery says CMS ruling doesn’t change its PMB policy
Family in battle with medical scheme to cover rare cancer drug