Millions spent on burn survivor but rehab denied
Kelvin van Baalen was resuscitated nine times and spent 413 days in intensive care after the accident in June last year
The mother of a young paraglider severely and extensively burnt after he glided into electricity lines is distraught over her medical scheme's decision to fund only 10 days of rehabilitation for the 22-year-old.
She believes the decision could undo the treatment it has paid for to date and her son's hard-won fight to survive.
Kelvin van Baalen was resuscitated nine times and spent 413 days in intensive care after the accident in June last year. Last month he was released from hospital and transferred to a rehabilitation facility to start a long process of learning to live with his still severe injuries.
Ten days of rehabilitation after 413 days in ICU. I am devastated!Leigh van Baalen,
Mother of burn victim Kelvin van Baalen
But after paying in excess of R15-million for his treatment at the specialised burns unit at Milpark Hospital in Johannesburg, Genesis Medical Scheme is refusing to pay for more than 10 days in rehabilitation, despite arguments that the benefit is a minimum benefit all schemes must provide.
The 10 days ended this week and Leigh van Baalen is now using funds raised by friends and family to pay the fee of about R8,000 a day at the Netcare Rehabilitation Hospital.
Assisted by consumer health-care rights activist Angela Drescher, Van Baalen has complained to the Council for Medical Schemes, saying Kelvin still has open wounds, tremors and is unable to walk or use his hands.
"Ten days of rehabilitation for a man who has been in ICU for 413 days. I am devastated! Disappointed! And heartbroken!" Van Baalen said in her complaint.
Annerie du Plooy, the founder of the not-for-profit Hero Burn Foundation, which assists burn survivors, says it is "inhumane" for Genesis to deny Kelvin the opportunity to heal given what burn survivors go through.
She says Kelvin has lost muscle mass and bone density, putting him at high risk of breaking bones. He has problems with his lungs and is at risk of organ failure relapse.
In addition, as with other burn survivors spending much shorter periods in intensive care, he probably also has ICU syndrome, a form of paranoia, and severe post-traumatic stress disorder, which will need to be dealt with in therapy.
The medical team treating Kelvin have recommended at least 12 weeks in the rehabilitation facility, Van Baalen says.
Regulations under the Medical Schemes Act state that burns covering more than 10% of the body surface are a PMB (prescribed minimum benefit) and the treatment includes removal of damaged tissue, skin grafts and medical management.
In a 2011/2012 publication, CMS Script, the Council for Medical Schemes (CMS) says depending on the severity and nature of the burns, PMB treatment may require rehabilitation such as physiotherapy, occupational therapy and speech therapy, Drescher says.
The medical scheme regulator said this week it could not comment on the merits of the case as its investigation is continuing. It said the PMB level of care for rehabilitation is not specifically stipulated in the regulations under the Medical Schemes Act, but is provided for in state hospitals. Care provided in state hospitals is typically used by the regulator as the minimum standard for PMBs.
The amount a scheme has spent so
far treating a burn victim in hospital
The council also said treatment would only qualify as a PMB as long as there was a "functional benefit" in the rehabilitation.
Genesis's marketing manager, Elmarie Jensen, told Money the rehabilitation programme recommended for Kelvin is not a PMB and goes well beyond PMB-level care.
She says the availability of treatment in state facilities does not make it a PMB. The scheme has paid for Kelvin's treatment in one of the best private hospitals and by the best doctors and specialists. The scheme's rules now provide for only 10 days in rehabilitation and it would be unfair to other members to extend the benefit, she says.
Casper Venter, a director at HealthMan, a consultancy for specialists; Magda Fourie, a professional liaison consultant at the South African Society of Physiotherapy; and David Green, divisional head of health at Constantia Insurance's Med ClaimAssist, are, how-ever, all of the view that a scheme cannot limit the rehabilitation benefit after burns as Genesis has, because it is covered by the PMB regulations.
Venter says the PMBs were designed to give members cover for just such catastrophes, regardless of how many millions it costs.
That is what insurance is about, he says.
Fourie says a scheme would be within its rights to ask for a treatment plan, but to limit the number of days of rehabilitation after burns when there is a need for it would appear to contradict the PMB regulations.
She says physiotherapists, speech and
occupational therapists all have a lot of problems getting schemes to cover rehabilitation, even when it is a PMB.
The society is working with the CMS on making it clear in the PMB algorithms and clinical guidelines what treatment schemes should cover.
Green says the CMS complaints process is too slow to assist people like Kelvin, but he has succeeded in persuading a scheme to continue paying on an ex gratia basis for expensive life-sustaining medication while a complaint was heard.
Du Plooy says this is the foundation's first case in which a scheme has refused to fund rehabilitation in line with a survivor's needs.
Herself a burn survivor after a plane crash, Du Plooy spent six months in hospital and rehabilitation and had reconstructive surgery years later that was funded by Discovery Health Medical Scheme's top option.
Schemes need a deeper understanding of burn survivors' needs in coping with the clinical impact and their new, altered life, she says. An in-depth review of the PMBs related to burns treatment by schemes is needed, she says.