The medical aid scheme is facing a moral backlash from doctors and patients who accuse it of making huge profits while its members die from a treatable infection. Chen Blignaut reports
Aids specialists and lawyers have accused the country’s wealthiest private medical aid scheme, Discovery Health, of “handing down death sentences” by “duping” members into believing they are covered for HIV, when the most meaningful treatment they can get is friendly advice.
At least one patient, who believed he was covered for HIV treatment and who subsequently discovered he was not, has since died, because he couldn’t afford anti-retroviral drugs.
The Aids Law Project (ALP) this week confirmed it was considering legal action against Discovery Health on the basis of negligent misrepresentation about its coverage of HIV/Aids, after complaints from doctors and patients.
The ALP will also send a letter to the Medical Schemes Council to complain about the company’s “morally reprehensible behaviour”, said ALP lawyer Liesl Gerntholtz.
“They market themselves as a compassionate medical aid, saying we’ll take care of you if you’re HIV-positive, but when you need their help, you discover you’re actually covered for nothing at all. You’d get the same treatment as when you’d go to your local state hospital,” she said.
Discovery Health is facing a moral backlash from doctors and patients who accuse it of making huge profits and expanding its business to the United States while its members in South Africa are dying from a treatable infection. Ironically, the company will pay for anti-retroviral treatment in US, where Aids is far less prevalent.
Discovery Health’s general manager, Alan Pollard, has strongly denied the company had ever misrepresented any information and insisted the “general perception” out there was that the company didn’t cover any Aids-related costs, when they did in fact offer “partial” coverage. He said the company had always had “a moral problem” with HIV/Aids and “would dearly love” to cover anti-retroviral therapy, but that it was simply not financially viable, because it would cause subscriptions to “spiral” out of control.
The company would, however, be “looking at restricted anti-retroviral treatment before the end of the year”, Pollard said.
The University of Cape Town’s (UCT) leading HIV expert, Professor Robin Wood, said other medical aids such as Medscheme have shown that anti-retroviral therapy is cost-saving in the medium term.
Dr Douglas Wilson, a physician from UCT’s HIV research unit, approached Discovery Health about “misleading” and “deceitful” information last year after he unsuccessfully tried to get anti-retroviral treatment for a patient on Discovery Health, who died three months ago.
“He showed me his medical aid card and a photocopy of a Discovery Health brochure, which he believed covered him for HIV.” When Wilson phoned the company, he discovered his patient was not entitled to anti-retroviral treatment.
“It was awful. I had to tell him there was nothing I could do for him,” Wilson said.
The doctor, who tried repeatedly and unsuccessfully to get a satisfactory explanation from Discovery Health, believes his patient’s death could have been prevented.
“Not paying for anti-retrovirals is a death sentence handed down by a company that is making huge profits,” he said. Discovery Health declared a R120-million operating profit last year.
Discovery Health has come under fire for marketing itself aggressively to young professionals, considered a high-risk group for contracting HIV/Aids, when it doesn’t pay for the treatment of the disease most likely to affect this group.
“It’s the same as when you say you’ll take care of all 40-year-old men, but then you exclude heart attacks, or you say you’ll look after women and you exclude pregnancy and breast cancer,” said Wood.
The first claim of misrepresentation against Discovery Health relates to information in the company’s trendy fact-file, which states in bold letters: “We cover you for Aids.”
What this actually means is patients have to self-fund drugs, GP visits and pathology tests from their own, usually very limited, medical savings account. After that, only members who had taken out a comprehensive plan would be entitled to further GP visits, acute medication with a limit of R10 000, homeopathy, pathology tests and other services.
There is also a R15 000-a-family-a-year cap on private hospital cover in the case of HIV-related illnesses, which would normally cover only a few days, after which the patient would have to vie with thousands of other unfortunates straining the resources of public hospitals.
Nowhere in Discovery’s detailed reference guide does it mention that anti-retroviral drugs are not covered, not even under “exclusions”. Members are advised to enrol in an “HIV programme”, comprising a single biochemist offering telephonic advice on the management of the disease.
The second claim of misrepresentation is from HIV-positive patients who say they had been told by independent brokers marketing the medical aid scheme they’d be covered for anti-retroviral drugs, which turned out not to be true.
The Mail & Guardian spoke to two HIV-positive people, who didn’t want to be named for fear of stigmatisation, who claimed to have been “duped” in this way. Discovery Health only uses independent brokers, who are paid commission for enrolling new members.
Pollard said the brochure “must be an old one” and that the new fact files and benefit guidelines explicitly stated the exclusion of anti-retroviral treatment.
He said the new brochures had been sent out to members who joined since January 2001, although a media report on March 31 quotes the company as saying the booklet was “now under revision at the printers”.
Pollard denied the brochures had been changed because of complaints of misrepresentation, saying they’d been “updated”. He said the company would “take action” against brokers proven to have misled clients.
Cape Town businessman Tom O’Neill is also seeking legal advice because he believes he had been “misinformed” by Discovery Health. O’Neill persuaded 55 staff members to join the scheme, believing they’d be covered for HIV treatment. He only discovered later this was not the case.
An informal survey of his mostly tertiary-educated staff showed that only two realised their Discovery membership didn’t entitle them to anti-retroviral drugs.
One HIV-positive member of Discovery, who claims he’d been wrongly informed by a broker, had this to say about the company: “They should stop luring people with promises of free aeroplane trips and cheap gym deals. All I want is for them to pay for my medication.”