Cancer happens when cells grow out of control; normal cells turn into abnormal ones and then multiply rapidly, crowding out healthy cells. Instead of dying off and being replaced like normal cells, cancer cells live longer. Some cancers affect only a specific area, while others spread.

The most common childhood cancers are unsurprisingly found in developing cells, such as blood and bone marrow (leukaemia), the immune system (lymphoma), the brain and nervous system (brain tumours and neuroblastomas), kidneys, skeletal tissues (sarcomas) and eyes (retinoblastomas).

There are three types of treatment for childhood cancers: chemotherapy (oral or intravenous medicines), radiation therapy (X-rays), and surgery. They can be given individually or as a combination.

Typically, the doctor (a paediatric oncologist or haematologist, ideally), will consider the following factors when considering treatment: the type of cancer; its stage; how fast it’s growing; whether it has spread to other parts of the body and if so, where and how far; and the child’s age, symptoms and general health.

Feedback from experts in the oncology field is that the first healthcare provider you consult can prove the most important in determining an outcome.

Clinical protocols

Discovery Health Medical Scheme (DHMS) applies highly researched evidence-based clinical protocols and guidelines. These treatment protocols are developed by the South African Oncology Consortium (SAOC) Paediatric Oncology Panel of experts which comprises some of South Africa’s best paediatric oncologists and haematologists from both the academic and private sectors. These clinical protocols are comparable to best international practice and are made available to all DHMS members after a careful and holistic review of each application made to the scheme.

Cover limits and essential tips

DHMS has a dedicated oncology benefit across plans. DHMS covers the first R200 000 or R400 000 (on all plans except KeyCare series, depending on the member’s chosen plan) of each beneficiary’s approved cancer treatment over a 12-month rolling cycle in full, up to the Discovery Health rate.

However, when a member exceeds these amounts (limits being plan-dependent), the scheme will pay up to 80% of the scheme rate of all further treatment costs. The co-payment amount can be higher if you use a healthcare provider outside the Discovery Health network, because they may charge higher than the scheme rate.

Members who belong to the KeyCare series are eligible for Prescribed Minimum Benefit (PMB) level treatment only. They can receive funding in full if their treatment complies with specific treatment protocols and if they obtain their treatment within an approved network.

The first reassurance that might help reduce stress for everyone in the family, is that most cancer conditions are listed as PMB conditions. That means by law, you must get a basic level of cover funded by your medical scheme in full, without co-payment and overall limits, provided it is clinically appropriate. This includes diagnosis, treatment and ongoing care.

No matter what medical scheme or plan you’re on, your basic needs will be attended to, and no co-payments or levies are chargeable – so long as you follow specific rules. However – and this is a major caveat – PMB cover is often not enough; this is where your medical aid and/or relevant plan can play a huge role.

The full ambit of treatments, in the 12-month period within the rand limits, is available at www.discovery.co.za, while disputes are resolved by a special appeals committee (call 0860 99 88 77).

If your child is diagnosed with cancer, remember to register him or her on the Oncology Programme. In order to register, you must send us reports (pathology and radiology results, and your treating doctors clinical motivation if necessary) confirming the diagnosis to [email protected]. You may also call us on 0860 99 88 77 for guidance.

Claims

Send all your accounts to Discovery Health within four months of service (or the claim will lapse). It is wise to keep a dedicated folder containing your membership number, service dates and types, healthcare providers’ details and practice number, consultation and diagnostic costs, ICD 10 codes (there’s one for every kind of consult or treatment), and receipts – whenever you’ve paid upfront. You must double-check to ensure all codes in the claims are correct and relevant to the treatment, thus saving yourself potential hassles to ensure processing of claims is hassle-free.

Palliative care

Discovery Health’s basket of care also covers full multi-disciplinary palliative home care with a dedicated facilitator to handle all funding and healthcare.