Battle joined over medical scheme coverage

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The Department of Health plans to change the regulation that ensures that medical aids pay for certain diseases no matter the cost. At the same time‚ a court case over the regulation has begun in the Western Cape High Court, reports Business Day.

Currently‚ the Medical Schemes Act ensures that prescribed minimum benefits (PMBs) cover 26 chronic diseases‚ 270 other conditions and life-threatening emergencies‚ and have to be paid for “in full” by medical schemes. This protects consumers and ensures they do not run out of funds for certain diseases halfway through the year. These prescribed minimum benefit conditions include HIV‚ emergency conditions‚ tuberculosis (TB)‚ diabetes and rheumatoid arthritis.

This protects consumers and ensures they do not run out of funds for certain diseases halfway through the year.
These prescribed minimum benefit conditions include HIV‚ emergency conditions‚ tuberculosis (TB)‚ diabetes and rheumatoid arthritis. Before prescribed minimum benefits were made law‚ patients with chronic diseases such as diabetes would run out of funds for monthly treatment halfway through the year. Now they get treatment.

But Genesis Medical Scheme has asked the court to change the regulation that ensures prescribed minimum benefits are paid for in full. The scheme is arguing that the fact certain diseases are covered no matter the cost leads to high doctor and hospital charges‚ which strain medical aids and increase monthly premiums. This means fewer people will be able to afford medical schemes in future‚ argues the scheme.

Data show that some doctors overcharge for procedures that are prescribed minimum benefits as they know their fees will be paid in full no matter the cost. There is no regulation on what doctors can charge. Genesis wants the benefits capped.


The health minister was cited as the only respondent in the case‚ but he did not oppose the Genesis application to change the law and reduce medical aid benefits. Essentially this means the minister is not arguing against the medical aid’s attempts to reduce benefits. This is a concern for non-governmental organisations (NGOs) that represent chronic disease patients.

But Health department spokesperson Joe Maila said: “We have decided not to oppose the case because we are amending regulation 8 of (the) Medical Schemes Act (that ensures PMBs are paid for‚ no matter the cost). The process of amending the regulations is at an advanced stage soon to be published for public comment”.

The TAC, South African Depression & Anxiety Group (SADAG) and People Living with Cancer (PLWC) have applied as friends of the court. A Groundup report says that although this was initially opposed by Genesis, they withdrew their opposition, and it is likely the three organisations will be admitted.

However, Genesis has opposed nine further parties joining the case as respondents. These are Medi-clinic Southern Africa, Hospital Association of South Africa, Council for Medical Schemes, Registrar of Medical Schemes, B Braun Avitum, Multiple Sclerosis Society of South Africa, Infertility Awareness Association of South Africa, The South African Private Practitioners Forum and Peter Francois Colin.

The TAC is arguing that the law that provides for the Minister to determine the PMBs, does allow him to regulate the scope of payment by the medical schemes, else the law would be pointless. Cassey Chambers of SADAG said the organisation is very concerned about the removal of the requirement to pay in full. “Many patients with mental health conditions will not be able to afford to pay or co-pay for the medicines they need and will land up in hospital with even more serious conditions.” Linda Greeff of PLWC said, “Many cancer treatments will simply be out of reach for anyone without the guarantee of payment for PMB conditions related to cancer.”

Some of the parties opposing Genesis’s action are providers of emergency or chronic treatment. Currently, they have certainty they will be paid for treatment of the PMB conditions of patients who belong to medical schemes. They are concerned that if Genesis wins, that certainty will be removed.

The report says according to the Council for Medical Schemes’ website, the PMBs were primarily created to ensure that medical scheme members have continuous healthcare and that PMB conditions are covered by a medical scheme regardless of whether patients are treated at state or private hospitals. According to CMS figures, prescribed minimum benefits cost R512 a month per member. The CMS voiced concern that members will be prejudiced if minimum benefits are capped.

In response to blogger criticism on GroundUp, Genesis that it was important to note that medical schemes did not set prices. “They take prices so that all we can do is pass on to our members in the form of higher contributions the high costs that we are charged by doctors and hospitals. Is that what you are after? Look at the parties in court yesterday – all there to protect their commercial profits. Instead of asking why medical schemes won’t pay in full, rather ask why are some service provider charges so high? Surely you know why the Healthcare Commission of Enquiry was established? To investigate the high cost of healthcare funding.

“Medical schemes are not the cause of that problem … Regulation 8 gives every healthcare service provider a blank cheque to charge what they like… It is unfortunate that the TAC and others have failed to explain how regulation 8 affects the Minister’s proclamation that chronic diseases must be treated to the extent provided in the therapeutic algorithm published in the Government Gazette.

“The Genesis action challenges the Minister of Healths’ legal capacity to pass regulation 8 into law without the sanction of Parliament.”

Full Business Day report
Full Groundup report

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