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CMS: Guaranteed medical scheme benefits stand

17 May 2012 Council for Medical Schemes (CMS)

The BHF and SAMWUMed have failed to convince a court to allow them to appeal against a judgement in which the court had confirmed that the prescribed minimum benefits (PMBs) guaranteed to members of medical schemes stand – and that the BHF had no legal st

Their application for leave to appeal against the judgement of 7 November 2011 was dismissed with costs by the North Gauteng High Court in Pretoria on Friday.

The BHF is the Board of Healthcare Funders of Southern Africa, a representative body for medical schemes and administrators. SAMWUMed is the South African Municipal Workers’ Union National Medical Scheme.

The Registrar of Medical Schemes and Chief Executive of the Council for Medical Schemes (CMS), Dr Monwabisi Gantsho, reiterated his concern over the BHF’s allegedly frivolous use of funds to initiate legal action, exacerbated by the fact that the BHF had little chance of succeeding in the first place.

"The BHF is funded by member schemes who in turn are funded by the monthly contributions they receive from their members," said Dr Gantsho. "It is extremely worrisome that members’ funds are being used to fight provisions which, ironically, are there to protect members’ interests."

The BHF and SAMWUMed had been trying to challenge Regulation 8 of the Medical Schemes Act 131 of 1998 for almost a year. Regulation 8 states that medical schemes must pay for the diagnosis, treatment and care of all PMB conditions in full, or at the price charged by the healthcare provider. The BHF and SAMWUMed were seeking to have the Regulation interpreted to mean that schemes must pay for PMB conditions only up to the scheme tariff, effectively changing the meaning and purpose of the PMB provisions in the Medical Schemes Act.

The CMS was one of 13 respondents in the matter. Other respondents included the Minister of Health, the Hospital Association of South Africa (HASA), the South African Private Practitioners Forum (SAPPF), and the South African Medical Association (SAMA).

The CMS is the custodian of the Medical Schemes Act and has always stood by a straightforward interpretation and implementation of the provisions on PMBs.

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