Medical aid scheme refuses to pay for local doctor's cancer treatment

He’s used to giving life-changing diagnoses, but nothing prepared this doctor for his own cancer battle – or the fight with the medical-aid scheme that refused to pay.

He’s usually on the other side of the table, telling patients news that could change their lives forever. And when the tables were turned and he was on the receiving end of a devastating diagnosis, he knew he could handle it. As a doctor he was well aware of what lay ahead: the symptoms, the treatment and just how hard he would need to fight in his battle for survival.

And then a major curveball was thrown Dr Sipho Bvuma’s way: his medical aid refused to pay for the drugs he knew could save his life. Sipho (49) had stage four brain cancer and asked the government medical-aid scheme, Gems, to pay for a special drug treatment called Keytruda – and was shocked when they turned him down.

"Too far gone... "

But Sipho, who works at Joburg’s Chris Hani Baragwanath Academic Hospital, refused to take no for an answer.  He took Gems to court, arguing that the drug would prolong his life and move him into remission. Gems argued they couldn’t cover the drug because “I was too far gone to waste money on the treatment and the treatment wasn’t on its list,” Sipho tells DRUM.

But within days Gems did an about turn and offered to pay for 16 rounds of the treatment, which costs nearly R500 000. “If I didn’t get this treatment, I was going to die a painful death.”

He’s now receiving one treatment every 21 days and he’d had two rounds when we saw him.

Changed position

According to Gems CEO Dr Stan Moloabi, the scheme initially didn’t approve his application “based on the fact the medication is not registered in South Africa as a treatment option for the specific type of cancer that Dr Bvuma required treatment for”.

Following  an  internal  process they changed their position and were able to fund the medicine on an ex-gratia basis – which means they’ll cover the  full  cycle  of  treatment. Sipho admits he was frustrated by the way the medical aid refused to entertain his request at first, deciding his cancer was too advanced to warrant treatment.

Death was looming

“That was the painful part of it,” he says. “Listening to someone who is not a doctor pronouncing death on me.” Sipho has been battling cancer for more than two years. He was diagnosed with renal cell carcinoma in 2016, a complication related to repeated exposure to bilharzia, a condition where parasites found in contaminated fresh water enter a person’s system via the skin.

“Growing up we often used to swim in dirty water,” he recalls. Symptoms  of  bilharzia  include  urinating  blood  and Sipho, who grew up in Xihoko  village  in  Limpopo,  didn’t  take  the symptoms  seriously  at  first  when  he  noticed blood in his urine. “I just thought I had a simple urinary tract infection,” he recalls.

But when he was still passing blood after a round of antibiotics, he knew something was wrong. “Eventually I went for a scan that showed I had a tumour,” he says. “I had kidney cancer.” Subsequent tests revealed the cancer had spread to his abdomen and chest. After gruelling chemotherapy sessions the tumours started to shrink – but that wasn’t the end of it.

Under pressure

“I started experiencing headaches, nausea and vomiting – which are clear signs there is increased pressure on the brain,” he says. After going for another consultation, it was found cancer had caused blockages in the brain, which was causing the pressure inside his head. “I knew it meant the cancer would destroy the whole brain and I would die.”

He had an operation to relieve the pressure and has undergone chemotherapy and hopes now that he’s won his Gems case the new medication will zap the tumours and leave him cancer free. Apart from short breaks for treatment and recuperating from the after effects, Sipho has been actively working at Bara. Yet the cancer has taken its toll on both his physical and mental health, he admits.

Medicine is his life

He also finds it traumatic when he’s treating patients who are undergoing similar experiences. “It reminds me of what I’m going through and depresses me.” But nothing will stop him from doing his job, the father of three – Nsobo (21), Mikhenso (16) and Sesi (15) – says.

Medicine is his life, something he knew he wanted to do since he was a high-school kid in the 1980s.  His fascination with the profession started when he saw his older brother, Basil (now 52), being stung by a wasp. “He had an allergic reaction and I was intrigued by the effect it had on him and the treatment he received.

“I read about it and researched the drips they gave him and that was all it took – I decided to be a doctor there and then.”

Isn't the first time

This isn’t the first time Sipho has gone head-to-head with Gems. After his kidney cancer diagnosis in 2016, the medical aid argued they couldn’t cover a procedure he required called Gamma Knife radiation.

“Gems refused to cover it so I had to go to court,” he says. The high court ruled in his favour: Gems had to pay for both the treatment and the costs of the case. But despite the ruling he’s still getting emails from the hospital where the procedure occurred, requesting payment. Gems’ Dr Moloabi tells DRUM “all the accounts relating to the 2016 Gamma Knife radiation treatment have been settled according to our records”.

The medical aid would look into the ongoing requests for payment, he added. It’s all very frustrating, Sipho says. “The medical aid isn’t doing me a favour by paying for my treatment. It’s what they should do. I pay premiums every month, more than R3 000 every month. They need to pay what they’re supposed to.” Fighting cancer is bad enough, he adds. “Then medical aid worsens the situation and gives you extra depression, which you don’t need and don’t expect.”

Preparing for death

During his battle with his medical aid, Sipho  admits  he  had  already  started  preparing for his death. “I was sure that they were going to pay for it. Without that treatment I would have been dead in nine months.”

He battled to maintain his faith at one stage and thought of moving home to Limpopo so he could die there. But with his recovery on track, he’s now focused on the future. And he wants to use his cancer battle to help him be a better doctor. “I want to specialise in cancer now,” he says. “It’s a subject no one likes speaking about but I think cancer – especially brain cancers – are very, very interesting.”

And when he’s well enough to tackle his new specialty he’ll have his experience of the potentially deathly disease to spur him on – as well as a first-hand account to share with patients about the power of never giving up.

Image credit: Drum