Escalation process – When access to treament is DENIED

When a cancer patient is first diagnosed, their doctor prescribes for them the treatment required to best treat their cancer. Sometimes this prescribed treatment is rejected by the patient’s medical aid for various reasons. 

There is currently limited access to concise, easy-to-understand information on the escalation process medical aid members need to embark on when denied access to treatment. This is further exacerbated by the lack of a “port of call” for patients that will help them navigate this process step by step.

So what does the process look like?

When you are diagnosed your treating doctor will discuss treatment options with you. Your doctor must explain the various procedures, and drugs that can be used to treat your cancer and all the side effects they may have. This is called ‘informed consent’ and it is a legal requirement.

Together, you and your doctor will agree on what your treatment will include. This will be your ‘treatment plan’.

Once your treatment plan is agreed upon, the process of informing your medical scheme about your condition begins.

Step 1:

Your doctor will submit your treatment plan to your medical scheme for them to agree to pay for the treatment.

Step 2: 

Your medical scheme will respond to your doctor stating which part of your treatment plan they agree to pay for. This normally takes a few days.


The medical scheme can accept the entire treatment plan as is and your doctor will inform you and your treatment can begin. OR The medical scheme can decline to pay all, or part of the treatment plan.

If this happens your doctor can either change your treatment plan or you can challenge the medical scheme’s decision.

WHAT If your Medical Scheme denies your treatment plan?

C4C makes available a hard copy document detailing the escalation process, which will be easily accessible by patients through healthcare provides, oncologists, nurses, social workers and access departments in private practices. With this flyer we wish to ensure that every cancer patient that is denied access to treatment, regardless of the reason, is informed about the escalation process they need to embark on to challenge their funder’s decision in a responsible manner.

It is of vital importance to the patient that any disputes get dealt with as quickly as possible, to enable them to acquire the necessary treatment, within the shortest time frame possible.

The escalation flyer graphically displays the necessary prescribed legal procedures and steps required for the patient to follow, clearly shown in a flow diagram layout (see below).

This process will dramatically speed up the process for the patient when dealing with denied treatment plans.

Adapted from a article. 


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