Medical schemes may not force you to go to state hospitals for PMBs

Health insurance – iStock
Health insurance – iStock

This is the end of the road for medical schemes wanting to limit the treatment of Prescribed Minimum Benefits to state hospitals. 

Genesis’ long journey through the courts

The Constitutional Court has rejected the application for appeal by the Genesis Medical Scheme against a decision by the Supreme Court of Appeal.  

This has concluded Genesis’ long journey through the courts about the payment of Prescribed Minimum Benefits (PMBs).

Read: Facts on PMBs

BMBs are a list of 270 conditions that all medical schemes are required by law to cover without applying any restrictions, as well as 25 chronic diseases and emergency care.  This includes the costs of the diagnosis, treatment and care of these conditions.   

According to the Council for Medical Schemes the application was rejected because the court believes that there is no chance of success and the costs were awarded to Genesis.

Daniel Lehutjo, acting head and registrar of the Council for Medical Schemes (CMS), says this brings an end to the debate about whether medical schemes are allowed, based on their own rules, to only pay for PMBs in state hospitals

The CMS said that the matter deals with the liability of a medical scheme to pay for a PMB that was treated in a private hospital.

Law trumps medical scheme rules

Genesis refused to pay for a condition that is required by law to be fully covered because the treatment was obtained in a private hospital, and their (Genesis’) rules prescribe that this treatment must be carried out in a state hospital.  

Read: Poor service also at private hospitals

“Medical schemes are compelled to appoint a specific service provider to limit patients’ exposure to the costs of BMBs and may not try to use their rules to circumvent their obligation to pay for these benefits,” said Lehutjo.

When Genesis wasn’t satisfied with the decision of the Supreme Court of Appeal, the medical scheme approached the Western Cape High Court to review the decision.  

The High Court ruled in favour of the scheme and found that its rules are binding and represent a binding contract between members and the scheme.

The CMS and the registrar then appealed against the decision on the point that the law always trumps the rules of a scheme. The scheme also hadn’t negotiated a designated service provider for its members. Article translated and adapted from Netwerk24

Read more:

Medical aid benefits case to be heard

What to consider when changing your medical scheme

Patients vote on SA’s best hospitals

Article translated and adapted from Netwerk24

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