Courts reinforce RAF position that it should not pay medical expenses already paid for by Medical Schemes

The Road Accident Fund (RAF) welcomes a recent judgment handed down in the Gauteng Local Division reinforcing the Fund’s stance that it is not obligated to reimburse medical aid schemes for costs incurred on behalf of their members.

This follows a claim by an accident victim for past medical expenses after the claimant’s medical aid, Bonitas, had already settled her medical invoices which totaled R1 425 849.74.

Bonitas is administered by Medscheme, a subsidiary of the AfroCentric Group. The Group is a health administration company which manages closed and open medical aid schemes including Bonitas Medical Fund, Fedhealth Medical Scheme, South African Police Service Medical Scheme (POLMED), and SABC Medical Scheme.

A Medscheme representative testified during the trial that there was an agreement between the claimant and Bonitas that the amount paid by Bonitas would be repaid by the claimant to the medical scheme upon her receiving compensation from the RAF in respect of this head of damage. The question for the court to determine was whether the medical vouchers already paid by Bonitas should form part of the damages suffered by the plaintiff. In other words, had the claimant suffered damages in respect of this head of damage if Bonitas had already paid the medical invoices as per Prescribed Minimum Benefits (PMBs) and Emergency Medical Conditions (EMCs).

In dismissing this head of damage, Acting Judge of the High Court, T Ngeno, found “. . . I am not persuaded that such benefits would accrue to the member of the medical scheme for the simple reason that once the defendant has settled the claim relating to past medical expenses already paid by the medical scheme, the plaintiff is bound by the medical agreement entered into by her and the medical scheme to pay the settled claim to the medical scheme. For that reason, I am of the view that the benefit accrues to the medical scheme and not the plaintiff.”

Acting Justice Ngeno’s finding was in alignment with the principles in the recent matter of Discovery Health (Pty) Ltd v Road Accident Fund and Another which held medical schemes are simply discharging their statutory obligations to pay PMBs and EMCs in full as required by the Medical Schemes Act (MSA) and its regulations 7 and 8. Discovery had sought relief from the courts after the RAF had stopped reimbursing medical schemes for the medical invoices already paid on behalf of their members. However, the case was dismissed by a full bench of the Gauteng Division, which agreed with the RAF’s argument that Discovery Health had no standing to bring such an application.

RAF CEO Collins Letsoalo said: “Once again we have been vindicated by this judgment. The Fund is still heavily criticised for its position on this matter, but we remain steadfast in our decision.”