Medical aid members have good cause to celebrate after a Pretoria High Court judge ruled that medical aid schemes must pay all prescribed minimum benefits (PMBs) in full.
Judge Cynthia Pretorius’s ruling on Monday marks the end of member co-payments.
This means the client will not have to augment the shortfall between medical aid rates and practitioner rates.
The benefits are the minimum level of diagnosis, treatment and care that medical aid schemes are obliged to pay, according to the Medical Schemes Act, in full from their risk pool as opposed to a member’s savings. They include 270 serious conditions such as cancer and TB, 25 chronic diseases and any emergency condition.
In a court case that took just under a year to finalise, the Board of Healthcare Funders of Southern Africa (BHF) and the SA Municipal Workers Union National Medical Scheme took on the Council for Medical Schemes and 12 other respondents, seeking to clarify the wording of regulation 8 of the act, which states that medical schemes must “pay in full”.
The BHF argued that the PMBs must be paid in full at medical scheme rates and not at prices charged by healthcare providers.
While the ruling has been widely welcomed and is seen as a victory for cash-strapped medical aid members, several bodies have warned of an “unintended consequence” of the ruling.
The organisations say the judgment has left the door wide open for doctors – none of whom are led by a standard set of tariffs – to abuse the system.
BHF spokeswoman Heidi Kruger expressed disappointment at the ruling, saying it undermined pricing reforms the government was trying to put in place to make health-care more accessible and affordable.
“We’re now sitting with an open-ended liability for medical schemes because doctors are still able to charge whatever they want, leaving schemes vulnerable.
“This judgment and the current behaviour by some providers is simply reinforcing the need to regulate costs relating to health care services.”
SA Medical Association chairman Dr Norman Mabasa called for a Competition Commission ruling, which banned tariff negotiations between medical schemes and service provider groups, to be “revisited”.
“This was not a misunderstanding of the PMB rules, but a development that can be directly attributed to absolutely no mechanism being available for providers and schemes to negotiate on tariffs and possible issues surrounding them,” he said.
Victor Crouser, head of coastal health at Alexander Forbes, said many smaller schemes could find themselves under financial pressure. This could drive members’ premiums to increase further.
Crouser said the effect to bigger schemes like Discovery Health and Bonitas, which made use of contracted network arrangements, would “not be massively huge”.
On average, medical aid schemes’ 2012 premiums increased by between 7 and 9 percent, yet coverage re-mains the same or, in some cases, less.
South Africa’s biggest medical aid scheme, Discovery Health, will increase premiums by 8.9 percent, while Bonitas Medical Fund and Fedhealth will increase by 8.4 and between 6.8 and 7.1 percent respectively. fedhealth has two increases for different packages.
Council for Medical Schemes registrar and chief executive Monwabisi Gantsho said non-compliant schemes and administrators would be slapped with financial penalties and could face legal action.
Kruger said the BHF’s legal counsel would be studying the judgment while they considered their legal options.
She said the BHF wanted to engage urgently with Health minister Aaron Motsoaledi. - The Star