A High Court judge has ruled in favour of Discovery Health by ordering the Road Accident Fund (RAF) to overturn a directive to reject accident victims' claims if a medical scheme had already paid for the expenses in question.
On 12 August, the RAF’s acting chief claims officer, Maria Rambauli, issued an internal directive to RAF managers instructing them to stop processing and payment of all past hospital and medical expense claims from medical scheme members with immediate effect.
“This directive was immediately implemented, resulting in a sudden cessation in settlements of all medical claims submitted by attorneys on behalf of medical schemes members for the reimbursement of accident-related medical expenses,” Discovery said.
“In simple terms, the RAF began rejecting valid medical claims submitted by people who are members of any medical scheme.” This was done without consulting or notifying medical schemes, their members or attorneys, reports BusinessLIVE.
Despite attempts to engage the RAF, “Discovery Health did not receive any response from senior leadership at the RAF”, the scheme said.
“Consequently, Discovery Health, on behalf of its administered client medical schemes and in the public interest, had no alternative but to launch an urgent application in the Gauteng High Court (Pretoria) against the RAF and the Transport Minister, seeking to interdict the RAF from implementing its directive.”
Judge Mandla Mbongwe agreed. “Discovery Health’s approach to the court could not be more justified and, in fact, coerced by the RAF’s directive,” he said. “The RAF chose to go rogue and arbitrary, without any consideration of the social benefit the (RAF) Act is intended to serve and the requisite consultative public engagement of all stakeholders, such as the schemes which alleviate the plight of motor vehicle accident victims.”
His states that the RAF is interdicted and restrained from implementing the directive. “This is an important victory for members of all medical schemes who have equal rights to benefit from the RAF support and who all make the same, significant fuel levy contributions,” Discovery Health CEO Dr Ryan Noach said after the ruling.
After paying members’ healthcare claims for road accident-related injuries, medical schemes submit the medical claim expenses as part of their members’ claims to the RAF. When the RAF settles the medical claims, it pays the money to the medical schemes.
What the RAF tried to do would have meant medical schemes suffered significant and unplanned loss of income, Discovery Health argued. Had the court not stopped the RAF from carrying out its plan, medical schemes may have resorted to excluding claims for medical expenses arising from car accidents. That would have entitled RAF claimants to claim for their past medical expenses from the fund, Discovery said.
“But this (would have) undermined the very purpose of the schemes, as members would have been forced to pay for their medical costs upfront, and claim from the RAF later.”
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