Medical scheme to pay in full

The Board of Healthcare Funders (BHF) will appeal against a court ruling that requires medical scheme to pay in full for prescribed minimum benefits' (PMB) conditions.

"The BHF believes the judgment is bad news for consumers, as the uncertainty with regards to pricing of healthcare will continue," it said in a statement on Thursday.

On Monday, the High Court in Pretoria ruled that PMBs, which protect members of medical schemes, must remain in place.

The BHF was one of the respondents in the case.

Clear understanding

It was hoping the court would give a clear understanding of the implications of regulation eight of the Medical Schemes Act 131 of 1998.

The regulation states that medical schemes must pay for the diagnosis, treatment and care of all PMB conditions in full, or at the price charged by the health care provider.

Therefore, private healthcare providers, could for example, inflate their prices with the knowledge that it exceeded costs that might be incurred by government hospitals, clinics and the like.

The industry body said it would appeal the ruling as the principles and merits of the matter did not appear to have been considered.

Sustainability affected

"We believe that this judgment may negatively affect the sustainability of medical schemes, which have been under severe financial pressure due to the opportunistic and reckless charging by some healthcare providers for PMB."

It said it was concerned that medical schemes may have no choice but to raise contribution premiums and this would affect its members.

"Over the past few years, the healthcare provider fraternity has been partly or fully responsible for the scrapping of all healthcare pricing guidelines and undermining the coding structure."

This had increased costs within the private healthcare sector.

"We believe that the judgment will allow this untenable situation to continue," said the BHF.

(Sapa, November 2011)

Read more:

Medical schemes - a history

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