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SUB CATEGORIES General  |  HIV |  Medical Schemes | 

CMS: Medical Schemes have to cover road accident claims says CMS

29 October 2014

The position of the Council for Medical Schemes (CMS) has always been that medical schemes have to pay all legitimate claims legally owing to members within 30 days of the claim being submitted as provided for by the Medical Schemes Act 131 of 1998. Further, pre-authorisation can also not be withheld pending the undertaking of a member to lodge a third party claim.

A press release to this effect was issued by the CMS in 2012. This press release also pointed out that medical schemes are allowed to require members in terms of the registered rules to refund the scheme where those members received any form of compensation for medical expenses from a third party. If a member’s medical expenses are covered by the medical scheme and by an organisation like the Road Accident Fund (RAF) or the Compensation Commission it would result in a double payment which constitutes unjustified enrichment.

The rules of a medical scheme is binding on the member, the scheme and any party claiming benefits from the scheme. It is standard practice for medical schemes to recover costs from a member where a third party has also made the payment but it is important to note that payment is made and later recovered, it should not be withheld from the onset when emergency medical care is most needed.

The CMS denies that it has found Discovery Health Medical Scheme to be in contravention of the Medical Schemes Act 131 of 1998 concerning matters where third party claims are involved. The office has previously received a complaint against Discovery Health Medical Scheme lodged by Mr. Bobroff, however the Registrar ruled in favour of Discovery Health Medical Scheme and the matter is currently the subject of an appeal.

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