The Council for Medical Schemes (CMS) appeals committee has instructed a medical scheme to fully fund a multimillion-rand treatment required by a 15-year-old suffering from a rare blood disorder – this after KeyHealth’s initial decision to provide only partial cover, reports Business Day.
The dispute centres on KeyHealth’s stand to not fully cover the costs of AstraZeneca’s ravulizumab as a treatment for paroxysmal nocturnal haemoglobinuria – classed as a prescribed minimum benefit (PMB) – and imposing a series of conditions on the family’s membership.
The child’s treatment with ravulizumab, branded Ultomiris, is expected to cost about R7.3m for the first year and R6.1m a year after that.
PMBs are a minimum basket of care that all medical schemes are legally obliged to cover for all their members, irrespective of which option or tier they’re on. The extent to which schemes can impose limits on this obligation has been fiercely contested for more than a decade, with schemes turning down requests for costly treatments they deem unaffordable.
However, in a ruling handed down on 29 October, the CMS appeals committee directed KeyHealth to provide full cover for the child’s treatment with ravulizumab without conditions.
“The statutory architecture is clear: once a condition is classified as a PMB, regulation 8(1) (of the Medical Schemes Act) imposes an absolute, non-negotiable obligation on the scheme to fund its diagnosis, treatment and care in full,” the committee said in its ruling.
It dismissed KeyHealth’s argument that it was only required to provide cover to the level offered by the public sector, which does not provide ravulizumab, saying the minor should not be penalised by the state’s outdated medicines list.
Ultomiris was registered with the European Medicines Agency in 2019 but only approved by the SA Health Products Regulatory Authority in May.
The committee found that the child’s condition had progressively deteriorated on supportive care and that KeyHealth was obliged by regulation 15 (h) of the Medical Schemes Act to provide alternative treatment without financial penalty, co-payments or compulsory option upgrades.
The appeals committee overturned the CMS registrar’s decision on 3 August, upholding KeyHealth’s position, which was that it would provide 50% cover for ravulizumab provided the child’s family agreed to various conditions, including switching to a more expensive plan, committing to remaining members of the scheme until end-2027, and agreeing to a review of funding if the child were admitted to hospital.
The office of the CMS registrar said it had received notice from KeyHealth that it intended to appeal the ruling with the CMS Appeals Board, but declined to comment on the implications of the ruling.
KeyHealth had not responded to Business Day’s request for comment at the time of publication.
MediCheck CEO Mark Hyman, who represents the child’s family, said he would seek a declaratory order from the high court to compel KeyHealth to immediately comply with the appeal committee ruling.
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