The recent decision of the Appeal Committee in B V Registrar of Medical Schemes and Motohealth Care highlights the need for members of schemes to read and understand the benefits that are provided by their scheme and more especially the benefit option to which they subscribe. In that case, notwithstanding the provisions of regulation 8 of the Medical Scheme Act (the Act) which expressly provide that any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of PMB Conditions, the Appeal Committee held that the medical scheme was not liable for the costs associated with a PMB Condition where a member subscribed to a specific benefit option. That is, the medical scheme was not liable for the costs of PMB Conditions where care was given while the member subscribed to the Custom benefit option.
In the Motohealth case the scheme had obtained an exemption from the Council for Medical Schemes (the Council) in terms of section 8(h) of the Act. Section 8(h) permits the Council to exempt a medical scheme, on written application, from complying with any provision of the Act. The Council had on 11 November 2009 exempted the Custom benefit from the obligation to provide hospital benefits and prescribed minimum benefits up until 31 December 2010. The appellant had received treatment and care for a PMB Condition in July 2010, that is, while the Custom benefit was exempt from complying with regulation 8. The Appeal Committee ruled in favour of the scheme, as it was validly exempted from funding PMB Conditions and could not be directed to make a payment given the exemption. However, the Appeal Committee stated clearly that any such exemption would need to be communicated to members in a clear and reasonable manner and that, to the extent that a member could prove that he or she was not aware of the exemption and the manner used to communicate such an exemption was flawed, it was then likely that the scheme would be held liable for such costs, notwithstanding the existence of an exemption.
Another recent decision by the Appeal Committee in the matter of B v Registrar of Medical scheme and Discovery Health Medical Scheme highlights the importance of members understanding that a medical scheme is only obliged to pay in full for a PMB Condition in accordance with the Diagnosis and Treatment Pairs, which attach to a specific condition as recorded in the regulations to the Act. In that instance the appellant took the stance that Discovery was obliged to fund the on-going cost of the medication prescribed for the treatment of Dystonia (a PMB Condition). However the Appeal Committee ruled that Discovery was only obliged to pay for the cost as stipulated in the Diagnosis and Treatment Pairs which, in the case of Dystonia, provides for the payment for “initial diagnosis; initiation of medical management”, that is, continued treatment was to be funded from available funds in the appellant’s day to day benefits.
It is important that members do not assume that their benefit option will cover PMB Conditions because of the scheme having a legal obligation. Members must ensure that they read their member booklets and other pertinent information they receive from their scheme in order to avoid having to pay for medical treatment out of their pockets. Members should also be well informed about the ambit of cover available for a specific PMB Condition, as recorded in the Diagnosis and Treatment Pairs. Members who initiate litigation, which has no legal basis, should be aware that they are wasting scheme funds that are ultimately supposed to be used for their benefit.
Schemes should also communicate to members that the scheme is only liable to pay the cost of PMB Conditions within specified parameters (for the specified treatment and care) that are recorded in the Act; that is, members should be made aware that a PMB Condition is not a blank cheque to be used indiscriminately.
