Notable ruling on medical aid
THE Supreme Court of Appeal has ruled that Genesis medical scheme must pay for Prescribed Minimum Benefits (PMBs) in full‚ regardless of what its own rules say.
PMBs are a basket of services that all schemes must provide to their members and include 270 medical conditions‚ 25 chronic conditions and emergency care.
The extent to which schemes are liable for PMBs costs is a fiercely contested issue in the medical schemes industry.
It is the focus of a separate legal matter in which Genesis is asking the Cape Town High Court to scrap regulation 8 of the Medical Schemes Act‚ which requires schemes to pay for the prescribed benefits in full.
Seen against this backdrop‚ the ruling handed down by Judge Eric Leach potentially has broader significance than the narrow fight between Genesis and a member of the scheme over payment for the treatment of a severely fractured leg.
“One of the underlying purposes of thePMBprovisions … is to ease the demand upon public resources … while at the same time ensuring that members of the medical scheme are able to obtain treatment at a satisfactory level … section 29 (1) (0) and regulation 8‚ which read together require a medical scheme to pay in full the costs of treatment of PMB conditions ... were clearly designed to ensure that members would not be obliged to bear the cost of providing such treatment‚” wrote Leach.
The court ruling relates to a legal battle between Genesis and the Council for Medical Schemes over Genesis’s refusal to pay for