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Discovery loses case over refusal to pay for patient's glaucoma implant

'Business Day' reported on Monday that the council’s ruling followed the case of a glaucoma patient who took on Discovery Health Medical Scheme over its refusal to pay for an implant that was recommended by a specialist.

FILE: Discovery Group offices in Sandton. Picture: Abigail Javier/EWN.

JOHANNESBURG - The Council for Medical Schemes (CMS) has paved the way for consumers to force the industry to pay for treatment that is not available in public hospitals.

Business Day reported on Monday that the council’s ruling followed the case of a glaucoma patient who took on Discovery Health Medical Scheme over its refusal to pay for an implant that was recommended by a specialist.

The scheme, which would have paid for treatment more than two times what the device costs, had argued that clinical evidence around the implant was weak.

It also argued it was legally entitled to refuse payment for the device because it was not available in state hospitals.

The ruling opens the door for patients to force the medical aid to fund any drug or medical care deemed necessary by a doctor to treat any disease that falls under a basic basket of care called Prescribed Minimum Benefits.

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