All eyes are on the case at Council for Medical Schemes as former champion athlete battles Discovery Health to get his cancer treatment paid for in full. A landmark ruling is in the offing that could clear a path to compel medical schemes to revise how they pay for multiple myeloma cancer treatments that schemes have until now declined, or approved but with burdens of hefty co-payments for patients. In this fight is 62-year-old Capetonian Oscar Chalupsky against Discovery Health Medical Scheme, the largest medical aid in the country, which has an estimated three million beneficiaries.
The matter first came before the Council for Medical Schemes for adjudication in January 2024. Chalupsky is a well-known sportsman having had a formidable sporting career. He is a 12-time Molokai Challenge surfski champion, multiple winner of the Umkomaas River Canoe Marathon and he represented South Africa in the 1992 Barcelona Olympics.
The case has centred around the funding of a cancer drug called Daratumumab (Darzalex) that Chalupsky needed as his cancer progressed. Chalupsky was diagnosed in 2019 with multiple myeloma, a blood cancer that affects plasma cells. It is classified as a prescribed minimum benefit condition under the Medical Schemes Act 1998.
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According to the Council for Medical Schemes, prescribed minimum benefits are a set of “essential healthcare services that all registered medical schemes are legally required to cover, regardless of the specific plan chosen. This ensures all members have access to continuous care for serious conditions.” Chalupsky started his treatment in June 2020. Three years later his maintenance cancer therapy failed and he suffered recurrent relapses.
Chalupsky’s doctor put him on Daratumumab because of his prior treatments and complications. He had also had melanomas (skin cancers). While the medical scheme approved the prescription it only paid 50% of the costs, said Chalupsky.
This left him having to lean on friends and family to help make up a shortfall, which he says came close to R300,000. With the support of the NGO Campaigning for Cancer that fights to help patients get the treatment they need without ending up in financial stress or ruin, Chalupsky lodged a complaint with the Council for Medical Schemes. His counsel argued that his treatment with the use of Daratumumab was medically justified and should have been paid in full in accordance with prescribed regulations.
Discovery argued that Chalupsky’s treatment didn’t follow their sequencing of treatment for his type of cancer, and that skipping to Daratumumab did not constitute prescribed minimum benefit treatment. The Council for Medical Schemes disagreed and ruled in favour of Chalupsky, finding that had his physician followed Discovery’s treatment protocol and used the drug listed for next use, it would have been ineffective or caused Chalupsky harm. The council also found that Daratumumab was the correct treatment choice and that it should have been paid for by the scheme in full.
But Discovery didn’t pay up. It appealed against the ruling – twice. This December another hearing was scheduled at the Council for Medical Schemes, but it has had to be postponed till early 2026.
The delays in finalising the case have now stretched into an almost two-year wait for Chalupsky to get his money back. As he waits he is currently a patient in a hospital in Shanghai, China, seeking advanced new treatment. It’s treatment he’s paying for out of his own pocket.
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