Our Cancer Cover benefit consists of three sub-categories, namely:Breast Reconstruction Cancer Treatment ShortfallsCancer Treatment Top-Up
When a client undergoes a mastectomy and/or reconstruction of an affected breast, and healthcare providers such as the surgeon and anaesthetist charge more than the rate the medical aid pays from a hospital or risk benefit, we assess the shortfalls under our Gap Cover benefit.
Our Breast Reconstruction benefit, on the other hand, covers the cost of a breast reconstruction of an unaffected breast when a client’s medical aid plan excludes this procedure from cover.
This benefit is available on Elite, Corporate Elite Plus and Corporate Elite options only, limited to 1 event of up to R 30 000 per person per lifetime, subject to the OPL.
IMPORTANT TO REMEMBER
A mastectomy of both an affected and unaffected breast and the reconstruction of an affected and unaffected breast must be done simultaneously.
Approximately 59% of patients have a mastectomy with a reconstruction done on the same day.
There are advantages of having both procedures done on the same day. The psychological benefit of retaining one’s breast is significant and the anaesthetic risk of a subsequent procedure is avoided.
There could be valid reasons why a mastectomy and breast reconstruction can’t be done on the same day. The specialist’s preference, stage of cancer, availability of sufficient spare tissue to achieve an acceptable result and physical wellbeing of the patient are all contributing factors.
We’ll review the medical reasons where procedures cannot be done simultaneously.For our benefit to apply, the breast cancer diagnosis of the affected breast must be Stage 2 or a higher stage diagnosis.
The benefit is a lifetime benefit which means cover doesn’t apply when a breast reconstruction of an unaffected breast was done prior to taking up cover on a Stratum Benefits Gap Cover policy.
We don’t cover the cost to have an unaffected breast removed but the cost of a breast reconstruction of an unaffected breast that the medical aid plan excludes from cover.
CANCER TREATMENT SHORTFALLS
We cover the difference in cost between what a healthcare provider charges and the rate the medical aid pays from an oncology benefit for healthcare services related to cancer treatment. Shortfalls can occur on healthcare providers’ and service providers’ accounts, such as oncologists’ consultations, pathology, chemotherapy, basic and specialised radiology, biological medication, etc.
This benefit also refunds co-payments related to cancer treatment when the oncology benefit limit provided by the medical aid is reached.
Example: Medical Aid X provides an oncology benefit of R 200 000 per person per year.
Client A is diagnosed with cancer in June 2020 and begins cancer treatment. In December 2020, the oncology benefit limit is reached and Medical Aid X requires the member to pay 20% co-payment for any oncology-related expenses.
Compact200, Elite, Corporate Compact200, Corporate Elite Plus and Corporate Elite offer an unlimited benefit, subject to the OPL.
CANCER TREATMENT TOP-UP
When the oncology benefit limit provided by the medical aid is reached, we’ll cover the cost of ongoing cancer treatment.
We place the client in the same position as they were in at the time of receiving a medical aid benefit. Treatment must continue according to the approved oncology treatment planand at the same oncology facility.
Elite, Corporate Elite Plus and Corporate Elite offer an unlimited benefit, subject to the OPL.
Compact200 and Corporate Compact200 offer a benefit limit of R 60 000 per person per year, subject to the OPL.
Our Cancer Cover benefits are subject to waiting periods, benefit and general exclusions.
A very important general exclusion to remember is that we don’t cover a second or subsequent breast reconstruction, regardless of whether the medical procedure is for the insertion and/or removal of a breast implant or whether it’s for cosmetic or medically necessary reasons.
Where an OPL is mentioned, it refers to R 165 000 per person per year.