Discovering declining non-cosmetic eye surgery

Discovery are refusing to cover a claim for eye surgery for my son. It is the same procedure that is covered in cataracts. My son has high axial myopia, which means that amongst other issues like migraines, his eyesight progressively deteriorates. His sight grading is already -15 and he is only 16 years old. I did an appeal as they suggested and forwarded the specialist's motivation letter and this is the response I received:

image Dear Michelle Neill

Member Number: ***

Mr Mazzinghi

Thank you for contacting us.

Your request for payment of your hospital admission

We have reviewed your request for cover for a lens insertion for Shane.

These are the details of your request:

Treating doctor Dr Ballim (Pr # ***) Codes H44.2 / 3059 / 0201 / *** We have reviewed your payment request, but unfortunately we will not pay for the treatment as Discovery Health Medical Scheme does not cover this treatment for degenerative myopia.

You will have to pay all accounts

If you decide to go ahead with the treatment, you will have to pay all the costs related to this treatment — including the hospital admission — yourself.

We make consistent and fair payment decisions in the interest of all our members

We recognise that the treating doctor is in the best position to make medical decisions about Shane's condition and treatment. When we decided, we did not question the diagnosis or the treatment the doctor recommended. As a healthcare funder, we decide on paying for treatment in such a way that we make sure Discovery Health Medical Scheme can cover claims now and in the future.

We have a responsibility to make sure members of the Scheme have access to quality healthcare in a way that stays affordable and sustainable.

Some of the ways we achieve this is in our plan and benefit design, the creation and application of payment policies and clinical protocols that we have developed using a rigorous, evidence-based decision-making process. This process also helps us to decide which procedures and treatment to exclude from cover.

We hope this clarifies our reasons for declining your payment request.

If you have any more questions, please visit www.discovery.co.za to log a query or call us on ***.

Regards Nicole Mascis Discovery Health (Pty) Ltd On behalf of Discovery Health Medical Scheme

I have since responded to Nicole Mascis to enquire as to whether they will pay for a corneal transplant, in the event of my son going blind.

I cannot believe that their main focus it to protect their fund. My son's degenerative eye condition is of no interest to them, which is shocking. They have told my that the surgery is viewed as cosmetic... Is sight cosmetic??