Do you know what your medical aid covers? Mom wins court battle after son’s treatment denied

Many consumers are left frustrated with medical aid companies refusing to pay for treatment despite monthly premiums.

A mother has been locked in a multi-year legal battle with Medihelp after they refused to fund enzyme treatment for her son’s rare genetic condition called Hunter’s syndrome.

The scheme said the cost of his enzyme replacement therapy, Elaprase, wasn’t a registered prescribed minimum benefit (PMB) and wasn't on his plan.

The mother took the case to court and won an order in 2022 for Medihelp to pay for the treatment pending an appeal.

In November, the high court found the scheme in contempt for not complying with the 2022 order.

Attorney Alexi Rosenzweig said that many of consumers' core issues with their respective medical aids often involve the PMB.

This refers to the conditions that medical aids are obligated to cover regardless of your plan.

She added that many companies often excluded treatments or only offered "ex gratia" payments (goodwill payments with no obligation), which contradicted their responsibility to cover all costs associated with PMB conditions.

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"He was diagnosed at the age of three with a rare condition and essentially all of his associated costs, not just the treatment, have been rejected. This is why we went to court on the basis of contempt," she said.

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"As a lay person, you aren’t supposed to know these things, which is why you have medical aid."

Rosenzweig hopes cases such as these will set a precedent that will oblige medical aids to fulfil their existing obligations to patients.

To listen to Rosenzweig in conversation with 947’s Drive with Thando, click the audio player below: