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COUNCIL FOR MEDICAL SCHEMES APPEAL COMMITTEE

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									                   COUNCIL FOR MEDICAL SCHEMES
                        APPEAL COMMITTEE



In the matter between:



MH                                                       Appellant



and



DISCOVERY HEALTH MEDICAL SCHEME                          Respondent




                  APPEAL COMMITTEE RULING
______________________________________________________________




1.     The appellant takes issue with the imposition upon him of a 12-month

       waiting period in respect of medical treatment related to a brain

       tumour. The imposition of this waiting period had the effect that the

       appellant was not covered for brain surgery that it was necessary for

       him to undergo during this period.



2.     The respondent’s intention to impose the waiting period in question

       was communicated to the appellant by way of a letter dated 21

       October 2004, and the condition was accepted by the appellant as a

       condition for his membership of the respondent on 25 October 2004

       when he signed the respondent’s letter.
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3.   The imposition of the waiting period arose from the disclosure by the

     appellant in his application form of the fact that he had had an

     operation to remove a brain tumour in 1988, and further that he was

     currently experiencing numbness in his legs and balance problems,

     the cause of which were unknown, but in respect of which he had

     been referred for further tests to determine if the tumour that had been

     removed in 1988 had regrown.



4.   In a general questionnaire completed on 14 September 2004 the

     appellant indicated that he had had a consultation with a neurologist

     with regard to this difficulty.



5.   In response to the completion of this questionnaire, the respondent

     wrote to the appellant on 17 September 2004 and indicated that it was

     unable to conclude its underwriting process pending the final medical

     diagnosis in writing with regard to the weakness in legs, balance

     problems and possible regrowth of the appellant’s tumour.



6.   Thereafter, on 21 September 2004, Dr R wrote to the respondent

     indicating that the appellant had symptoms consistent with a tumour

     recurrence, and indicating that if the tumour were to have recurred

     further surgery would be necessary.



7.   Dr R recorded that he could not make a definitive diagnosis until a
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      “good quality brain scan” had been performed.



8.    In light of the uncertainty regarding the appellant’s condition and as a

      result of his status as a late-joiner, the respondent accepted his

      application for membership, but subject to the condition-specific

      waiting period referred to above.      The respondent was entitled to

      impose such a condition in the circumstances.



9.    The appellant was not compelled to accept the condition proposed by

      the respondent, and could at that stage have withdrawn his application

      for membership. He chose not to do so and accepted the condition.



10.   In his submissions to the appeal committee, the appellant, who is a

      qualified lawyer, indicated that he understood the basis upon which

      medical schemes and other such institutions assess risk, but that he

      believed that he had been discriminated against on the basis of both

      his age and his state of health.



11.   The appeal committee can find no evidence that the respondent

      discriminated against the appellant on the basis of his age.



12.   As far as the question of discrimination on the basis of the state of the

      appellant’s health is concerned, it is correct that it was the state of the

      appellant’s health that resulted in the decision by the respondent to
                                     - 4-




      impose a condition-specific waiting period on him.         However, that

      practice is not discriminatory in the sense that the presence of pre-

      existing health problems in an application for medical insurance is

      precisely the reason why provision is made for the imposition of such

      waiting periods.



13.   What the appellant’s true grievance would appear to be is not that a

      waiting period was imposed in his specific circumstances, but that

      medical schemes have the power to impose such waiting periods at

      all.



14.   The imposition of condition specific waiting periods has been long

      accepted in the South African system of medical insurance, and the

      respondent’s practices in this regard are no different from those of

      other medical schemes.



15.   In the circumstances, although the appellant may feel hard done by at

      having had such waiting periods imposed upon him, the respondent

      cannot be criticised for having imposed same, and it cannot be said

      that the respondent acted in any way in conflict with its rules.



16.   In the circumstances, notwithstanding the sympathy that the appeal

      committee has with the appellant’s predicament, there is no basis for a

      complaint against the respondent and the appeal must, consequently,
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     fail.


DATED AT SANDTON THIS   DAY OF MARCH 2006-03-16


P R JAMMY

For: APPEAL COMMITTEE

								
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