Nearly 10 years after being kicked off her medical aid and accused of not disclosing existing medical conditions, a Cape Town woman who took Profmed Medical Scheme all the way to the Constitutional Court emerged victorious.
But Mignon Adelia Steyn was unable to celebrate her victory – she died last year of an unrelated illness, reports News24.
“We were fortunate to be able to see this through all the way, showing the medical aids that you can’t just treat people the way you want because you have bigger guns,” her husband Adrian said.
The Steyns’ battle with Profmed started in 2016 when, almost a year into their membership, the policy was cancelled.
Steyn, a music teacher, and her dependants, had undergone various procedures, totalling R400 000.
Claims were submitted for reimbursement, but in November that year, the scheme terminated the membership, with retrospective effect from 1 January 2016.
As a result, Profmed declined to settle the bills. This was based on Steyn’s alleged failure to disclose medical conditions, including, it said, a gastric ulcer and hip problems.
In further communication, Profmed said the termination was a result of her not divulging that she had undergone procedures, such as an MRI of the lumbar spine, a gastroscopy and colonoscopy.
Steyn lodged a complaint with the Council for Medical Schemes, but the registrar ruled in Profmed’s favour, finding that the failure to provide this material information hindered Profmed’s ability to perform a comprehensive risk assessment on her application, potentially resulting in the imposition of a waiting period had the information been properly disclosed.
She appealed against the decision, filing papers to show she had successfully applied for membership to a different medical aid without any issue.
Profmed, however, used her application to raise new grounds for the termination for not disclosing, among others, a hip arthroscopy – a minimally invasive procedure to identify and repair damage to the joint.
The council dismissed the appeal, finding that the non-disclosure of specifically gastritis, although a “lesser condition than a gastric ulcer”, was material.
She approached the appeal board, which upheld the council’s decision.
A determined Steyn then approached the Western Cape High Court to have the decisions reviewed and set aside, and for Profmed’s termination to be declared unlawful.
She won this round, as Judge James Lekhuleni found the arthroscopy was merely a diagnostic procedure, which showed there was nothing amiss with Steyn’s hip. As for the gastritis, he concluded that it was a common condition which a reasonable, prudent person would not deem as relevant to the risk of the insurer.
Profmed, however, appealed to the full Bench, which reversed the decision.
Steyn applied for special leave to appeal to the Supreme Court, but was unsuccessful.
She then set her sights on the Constitutional Court, but died on 12 January 2023, after her application had been filed.
In her papers, she had argued that a hip arthroscopy was merely a diagnostic tool, for which she could not be “expected to disclose a non-existent condition”.
Profmed’s application form didn’t require the disclosure of diagnostic procedures, her affidavit reads.
And in respect of gastritis, she pointed out that the gastroscopy had established that she did not have a gastric ulcer.
According to her, the scheme had presented no evidence that gastritis gave rise to a material risk on Profmed’s part. In addition, gastritis – which is the inflammation of the lining of the stomach – is not on its list of prescribed minimum benefits.
Profmed countered that Steyn had not made any representations regarding the hip arthroscopy to the appeal board. Furthermore, it argued that it was apparent from the detail required in the application form that the information regarding the gastric condition was “reasonably relevant to the risk and its assessment by an insurer”.
According to them, a reasonable person would consider a “gastric condition” relevant to their risk of assessment, especially when considering the facts surrounding Steyn’s condition, being the suspicion of a gastric ulcer, resulting in a hospital visit and a gastroscopy.
Justice Steven Majiedt, in his judgment delivered this week, said Steyn’s hip arthroscopy was performed in June 2014, 17 months before she applied for Profmed membership.
In terms of the Medical Schemes Act, an insurer may only require the provision of medical information within a year preceding the date of application, he pointed out.
Nevertheless, a mere diagnostic medical procedure, which resulted in no material diagnosis of a condition, could not be classified as a material non-disclosure and a prudent and reasonable person would not regard it as such, Majiedt found.
It appeared that Profmed had terminated Steyn’s membership based on a misconception that she suffered from a gastric ulcer, he said.
“Plainly, on the uncontested evidence, the gastroscopy in fact revealed that she was not suffering from a gastric ulcer, but gastritis, a common medical condition which presents as heartburn and can often be relieved by self-medication. The registrar, council and appeal board all overlooked the distinction between the two conditions,” Majiedt ruled.
He set aside the full Bench’s court judgment, further ordering Profmed to pay the Steyns’ legal costs.
According to Adrian, this saga could have been avoided if Profmed had simply given them a chance to state their case before the termination of their membership.
“But they didn’t even give us a chance to respond. I asked them to keep us covered, while I got confirmation from the doctors we had seen (to prove that no information had been withheld). They refused.”
The battle against Profmed was not only about the money, Adrian maintained.
“It was also about them essentially saying we were dishonest. The victory means that my wife’s name is cleared; we are vindicated. This is proof that we did nothing wrong.”
In addition to drawing from their bond, it took the Steyns three years to pay the hospitals and doctors after Profmed reversed their payments, Adrian recalled.
“There were many sleepless nights caused by the stress and strain. The longer the case went on, the more expensive it got,” he said.
The action drained them financially, with their legal costs coming to just more than R2m.
Steyn died of septicaemia, three days after being admitted to hospital for an infection, Adrian said.
She had turned 49 only days earlier.
“This is her case, in her name. She was a little person who took on a big medical scheme, refusing to back down. And she won.
“We had been dismayed by the lack of assistance we got, how we were treated with causal disregard (when challenging the termination of the membership). This wasn’t even intended to become a court battle.”
Profmed CEO Craig Comrie said they were still going through the judgment and would meet their legal team to understand its contents before commenting.
See more from MedicalBrief archives:
Top court to decide on medical aid information disclosures
Non-disclosure: Doctors should not attack medical schemes for acting