Money Desk
KeyHealth ordered to fully fund rare-disease treatment
The Council for Medical Schemes has ordered KeyHealth to provide full, unconditional funding for a teenager's rare blood disorder treatment.
The Council for Medical Schemes appeals committee ruled on 29 October 2026 that KeyHealth must fully fund treatment for a 15-year-old with paroxysmal nocturnal haemoglobinuria. The ruling directs the medical scheme to cover the patient’s treatment in full.
Treatment Cost And Conditions
Ravulizumab, marketed as Ultomiris, is estimated to cost R7.3m in the first year of treatment and R6.1m for each year thereafter. The estimated annual cost falls by R1.2m after the first year.
| Treatment period or condition | Cost or cover |
|---|---|
| First year | R7.3m |
| Each year thereafter | R6.1m |
| KeyHealth’s previous offer | 50% cover |
| Required membership period | Until the end of 2027 |
KeyHealth had offered to pay half of the treatment cost, which would leave the family responsible for the remaining 50%. Based on the estimates, that share would amount to R3.65m in the first year and R3.05m annually thereafter.
Access to the offer was conditional on the family moving to a more expensive KeyHealth plan. The family would also have had to commit to remaining members of the scheme until the end of 2027.
KeyHealth’s Financial Position
KeyHealth reported a solvency ratio of 46.1% and a net surplus of R249.1m for 2025. By the end of that year, the medical scheme had 78,000 beneficiaries.
KeyHealth has indicated that it intends to appeal the Council for Medical Schemes appeals committee’s ruling to the CMS Appeals Board.
In its ruling, the CMS appeals committee said the scheme’s funding duty arose from the treatment being classified as a prescribed minimum benefit. “The statutory architecture is clear: once a condition is classified as a PMB, regulation 8(1) (of the Medical Schemes Act) imposes an absolute, non-negotiable obligation on the scheme to fund its diagnosis, treatment and care in full,” the committee said.
