Court ruling keeps basic medical aid cover

2011-11-07 16:50

Johannesburg - Prescribed minimum benefits, which protect members of medical schemes, would remain in place, the Pretoria High Court ruled on Monday.

"We are delighted with this ruling," said registrar of medical schemes and CEO of the council for medical schemes, Monwabisi Gantsho.

The law which prescribed minimum benefits would stand, the council for medical schemes said in a statement.

The council for medical schemes was the first of 13 respondents in the matter.

The ruling came as a result of the Board of Healthcare Funders of SA (BHF), which challenged regulation eight of the Medical Schemes Act 131 of 1998 and asked the court to pronounce on it.

BHF represents a number of medical schemes and administrators, and was later joined by the SA Municipal Workers' Union national medical scheme.

Regulation eight states that medical schemes must pay for the diagnosis, treatment and care of all prescribed minimum benefits conditions in full, or at the price charged by the healthcare provider.

Prescribed minimum benefits are the minimum level of diagnosis, treatment and care that a medical scheme is obliged by law to cover.

The scheme must pay for all prescribed minimum benefit conditions in full and from its risk pool, not from a clients' savings account.

These benefits include 270 serious health conditions such as tuberculosis and cancer, any emergency condition, and 25 chronic diseases including epilepsy, asthma and hypertension.

"Prescribed minimum benefits are a cornerstone of the medical schemes act and they were included in legislation for a good reason: to protect beneficiaries against unforeseen ill health that may prove financially catastrophic for them," Gantsho said.

"As the regulator tasked with looking after the best interests of medical scheme beneficiaries, we are happy that our courts have confirmed the need for such protection in law."


  • boatmedic - 2011-11-07 16:59


  • Cracker - 2011-11-07 17:20

    We need doctors and lawyers but not at all costs. The State must regulate their activities and cost structures and do it stringently. If you don't wish to practice in either profession or participate in the associated activities because you don't think it worth your while, good. Just leave. It would be a far better option than a national health insurance. Keep the costs down and use subsidies if necessary to assist people. Private health care is reaching proportions so out of relation to what we can afford that drastic measures are called for. Non-regulation was tried and it failed. Ditto the legal profession.

      The doc - 2011-11-07 18:06

      i always wonder why doctors incomei are such a topic of public scrutiny & debate. There are no cries to regulate other professional incomes or the incomes of politicians.

      Cracker - 2011-11-07 18:55

      @ The doc One would have thought the reasons are obvious. Free enterprise yes but not when a profession gets out of hand. We can debate it endlessly but let's be fair and honest. What on earth is going on? The doctors are having a field day and the other medical industry leeches are cashing in. Mainly the medical scheme big shots. We can play around with arguments, linguistics, or whatever but the reality facing us is unpleasant and totally out of proportion in favour of opportunists. Clearly we can't all be or become doctors or lawyers. It would have been nice if we could. But somewhere the line has to be drawn and in the sense that society cannot go on being exploited by professionals. Loaded word "exploit" but something seriously is wrong when you have to pay a large percentage of your income out of fear for your medical security. As said, one can get into all kinds of arguments and value assessements. But somewhere the line must be drawn. If it includes regulating the professional environment then it probably needs to be done. At least the professionals have a choice. They can change profession or just retire. Which they will in any event not do. There must be a middle path acceptable to the professionals and the rest of society. That's about it. But the current situation is totally unacceptable. Thanks in no small measure to the excesses of the professionals.

      Tolerant - 2011-11-08 11:11

      Many doctors are also feeling the economy downturn and are seeing lower income medical aid patients for as little as R106 or even R50 per month. We can't go much lower than that, no wonder we don't want to work in the evenings anymore.

      Eishh - 2012-01-11 10:25

      If you want to buy a TV and Game charge R2500 and Marco R1890 for the same TV, and you buy it at Game, don't blame Game for it, blame yourself. Why do you shop around for TV's and other services but not for medical services. Don't blame the profession or medical funds. Note I am not related to either.

  • berni.venter - 2011-11-07 17:20

    Awesome... Now will someone with authority and clout please investigate the HUGE GAP between Prescribed Minimum Benefits and the rates charged by ALL MEDICAL PRACTITIONERS??? Disparities of anything from 100 to 500% Which basically means that the PMB is R500 but the medical practitioner charges R1,750... You have to pay in R1,250.

      Tikki6Pence - 2011-11-07 17:43

      @berni: PMB legislation is such that if your doctor charges you R1750.00 for the consultation FOR A PMB CONDITION, your medical aid must PAY IT IN FULL. They may not balance bill you or take the balance from your savings account. Paying a PMB from savings is also illegal as per the Medical Schemes act. Far too many medical aids are getting away with this.

      Ian - 2011-11-07 17:55

      You must be unlucky. I have never had a Medical practitioner's account where I have had to pay in. And that includes a few Hospital operations.

      Aonhealthcare - 2011-11-08 12:58

      Members have rights, they can dispute this. Proper knowledge of rules and informed consumers has allot of clout.

      Eishh - 2012-01-11 10:20

      Change your medical pracritioner! You have a choise. Most medical schemes that I know off, has agreements with a subtantial number of medical practitioners and hospitals to charge a set fee for a set procedure - this is also known as incontracted or network doctors. Remember we all contribute to a pool, the scheme takes a certain percentage for admin and profit and the remainder goes for benefits. If everyone claims more than they contribute, the fund goes bankrupt or you will have to contribute more. So, if your doctor charge R1750 for a R500 procedure and you stick to that doctor you are to blame and not the scheme - or do you expect me to contribute to you ill dicisions?

  • Ina - 2011-11-07 18:11

    I am so grateful for this ruling. As a pensioner, I can only afford the most basic medical aid cover, and the PMB ruling is a godsend.

      Aonhealthcare - 2011-11-08 13:10

      Medical schemes can have protocols and formularies in place but Regulation 15 of the regulations promulgated in terms of the Medical Schemes Act, also protect members of medical schemes against formularies and protocols that are ineffective, cause or would cause harm. In this case members are protected in that if such a situation can medically be proven appropriate substitution must be made without any co-payment by the member.

  • Pierre - 2011-11-07 18:19

    I wonder how happy people will be when more medical aids close down because the hospitals and doctors just charge what they want for PMB conditions. I have to agree with Cracker - there must be some kind of regulation here or the current funds will be stripped.

      Tikki6Pence - 2011-11-08 19:37

      Private Hospitals do not charge different rates for PMB's or non PMB's: They have negotiated rates with most medical schemes which are in fact lower than the normal rates the hospital would charge...All rates remain the same regardless of your diagnosis.

      Juliana - 2012-01-20 09:29

      My understanding is that Hospitals charge medical aid rate whether it is a PMB or not. Only time they charge more is when you are private.

  • windweaver - 2011-11-07 18:47

    Right, so doctors can charge what they like, as does a Sea Point GP practice who charges R 660 for a consultation just because it's a PMB. Also, why are closed schemes protected re PMB's yet open schemes are exploited to the hilt by the doctors??? If PMB's are to be paid from risk a medical aid needs to protect it's reserves, and the consumer doesn't want highter contributions with fewer benefits then something must be done to force the medical profession to charge reasonable prices for the service offered.

      Tolerant - 2011-11-08 10:55

      You are not forced to go and see your Sea Point GP, shop around. He or she will come around when the patients dry up.

      Aonhealthcare - 2011-11-08 12:48

      Yes, doctors can charge what they like and this should be dealt with by predicting what GP's can charge, i.e. the proper pricing committee. Closed medical schemes are in the same boat as open medical schemes.

  • specialist - 2011-11-08 09:07

    Mag mediesefondse nogsteeds a “designated” dokter as verskoning gebruik vir die feit dat hulle nie enige ander Spesialis of gewone dokter se rekening te opsigte van kanker pasiente ten volle wil betaal nie.

  • Vicky - 2011-11-08 11:58

    If an injury is classified as a PMB and approved as such by the medical aid, is the MA still allowed to impose a benefit limit on the prosthesis used? For instance: fractured hip requiring a hip replacement - prosthesis cost R60k - benefit limit R40k - patient is balance billed for the difference by private health care providers. What is the patient's legal rights in such an instance?

      Tolerant - 2011-11-08 12:51

      In a perfect world the scheme should pay for everything but it does not happen in practice. You should win a court case, but can we afford all the costs and attorney's?

  • Juliana - 2012-01-20 09:36

    Everyone looks at the Dr's for over charging but medical aids dont play ball most of the times. Like how they pay our accounts. The 1st code billed they will pay our 100% of medical aid rate, 2nd code billed they only pay 75% of medical aid rate, 3rd Code 50% of medical aid rate & 4th Code only 25%. This is where the crime is....if a code is R1000.00 doctors only get R250.00 - NOW if that fair????

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