Will my medical aid pay for a double mastectomy?

If you take the tough decision to have a double mastectomy to protect yourself from getting breast cancer, will your insurer pay? Angelique Ruzicka finds out.

A number of celebrities, including actress Angelina Jolie, have admitted to having taken genetic tests which revealed that they had a mutation of the BRCA-1 or BRCA-2 gene. Some, including Jolie, have as a result of this discovery opted to have a bilateral prophylactic mastectomy (BPM) to reduce the risks of getting breast cancer.

BPM is the surgical removal of both breasts, without any evidence of malignant disease in either of the breasts. It’s a drastic measure that has divided women and medical professionals across the world. But advocates of this treatment believe this is the only way for them.

The reason why BPMs reduces the chances of getting breast cancer is because the BRCA genes help us to suppress tumours. However, if these genes mutate this protection falls away. A paper published by the National Centre for Biotechnology Information (NCBI), an organisation that advances science and health by providing access to biomedical and genomic information, says 5% to 10% of breast and ovarian cancers result from the inheritance of mutations in the BRCA1 or BRCA2 gene. Women who carry BRCA1 or BRCA2 genes have a high risk of developing breast and ovarian cancer.  

“A prophylactic mastectomy has been shown to decrease the incidence of breast cancer by as much as 90 percent or more in BRCA 1 and BRCA 2 mutation carriers,”  says Dr Noluthando Nematswerani, Discovery Health clinical specialist.

But this is by no means the only option or correct course of action for everyone. Dr. Nosworthy a specialist physician and medical oncologist at Wits Donald Gordon Medical Centre says that if you find out that you have this faulty gene then you should discuss this in detail with your breast cancer specialist as there are alternatives. “It [a double mastectomy] should not be considered without lengthy consultation and counselling from the breast specialist,” he explains.

Will your insurer pay?

The BRCA 1 and 2 gene tests can be performed locally by various pathology laboratories and can vary in cost depending on the patient’s individual requirements.  “The cost of these tests are covered by most medical schemes, including Fedhealth, from the member’s out-of-hospital pathology benefits where member’s still have available funds in their OHEB/day-to-day pool. A co-payment may be levied where a member has reached safety net level,” says Peter Jordan principal officer of Fedhealth.

Discovery, meanwhile, also pays for the BRCA tests but the money has to be recovered from your available day-to-day benefits. Jordan adds that screening for BRCA1 and 2 should only be done in high risk individuals following a full assessment and pre-test counselling.

But should you choose to have a BPM would you be covered by your medical scheme? The answer isn’t always clear. Some medical schemes allow for the surgery subject to certain conditions. Dr Nematswerani, of Discovery Health says: “Discovery would cover patients requesting to do a prophylactic mastectomy subject to meeting specific clinical criteria and these include (but not limited to) a confirmed presence of BRCA1 and 2 genes tied in with a strong family history of breast cancer.”

And while Fedhealth will also allow for the surgery, certain criteria have to be met first. “Where members test positive for a gene mutations and only where all other managed care protocols and clinical criteria are met, would Fedhealth support funding of a prophylactic bilateral mastectomy in high risk individuals,”  says Jordan.

As for reconstructive surgery following a BPM, insurers will again only pay subject to certain conditions. “Fedhealth only covers breast reconstruction surgery after breast cancer surgery. The type of reconstruction covered depends on the type of cancer-surgery performed. Clinical criteria are applied to decide on funding for breast reconstruction surgery after cancer surgery. Cover is only extended where these criteria are met,” says Jordan.

Critical illness polices may too pay out if you decide to have a BPM on the recommendation of your physician. “Under Altrisk’s Core and Comprehensive Critical Illness Cover, 25% of the benefit amount applied for would be paid out for a unilateral or bilateral mastectomy for carcinoma in situ, or prophylactic unilateral or bilateral mastectomy performed upon clinical recommendation by the attending specialist,” says Dalene Allen, underwriting director at Altrisk.

Allen adds: “The following factors apply for a prophylactic mastectomy: breast and/or ovarian cancer in either a mother or sister before the age of 50 years; bilateral breast cancer in either a mother or sister; or confirmed BRCA 1 or 2 carrier status.”

Insurer BrightRock also confirmed their pay-out for prophylactic mastectomy (medically sanctioned) for a family history of breast cancer is 25% of the sum insured. “Some critical illness products will pay you 100% of your cover on your first claim, leaving you with no further benefits. While this is great at the time of the first claim, it could leave you exposed later on if you get sick again. Some products are tiered to the severity of your illness, to allow more than one pay-out. And some products may even offer you the ability to increase your initial pay-out for conditions like certain breast cancers where future progression of your condition, and future claims, are likely,” says BrightRock.

Scrutinise your medical and insurance cover

The sad reality is that cancer does not discriminate and anyone can be diagnosed with the disease. You should scrutinise the cover your medical scheme and other insurance policies (such as dread disease/critical illness and disability policies) offer to you, particularly if you have a strong history of cancer in your family. For more info on this click here.

“Medical aids are generally excellent when it comes to illnesses such as cancer,” says Dr. Peter Bond, chief medical officer at Old Mutual. “Most will cover 100% of the medical aid rates and some even 200 and 300 percent, depending o­n the plan you have. The problem is that super specialists, like oncologists, can charge up to 300 percent of medical aid rates, and people who are o­n more basic medical aid plans often have to pay the difference out of their own pockets. The answer is to have either severe illness or gap cover to cover these shortfalls.”

If you have any doubts, seek expert help. “Depending o­n the insurance company you choose, severe illness cover can also extend to heart attacks, strokes and Alzheimer’s. Speak to your financial adviser to find out what cover will best suit the life stage you are in,” adds Bond.





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