High Court to hear application to intervene in medical aid regulation case

In September 2014, Genesis Medical Scheme launched an application against the Minister of Health, asking the Western Cape High Court to review and set aside regulations that provide for the Prescribed Minimum Benefits (PMBs), which are made by the Minister in terms of the Medical Schemes Act.

Genesis believes the Minister’s powers are ultra vires (the Minister does not have the power to make these regulations) and that the Minister is only empowered to prescribe medical conditions in the Regulations and not how medical schemes are required to pay for the treatment of these conditions. The Minister has not opposed the application.

The Treatment Action Campaign (TAC), South African Depression & Anxiety Group (SADAG) and People Living with Cancer (PLWC), all patient advocacy groups, are applying as amici curiae (friends of the court) to the Western Cape High Court, as they believe that if Genesis is successful, patients would suffer and their rights would potentially be violated.

A number of other interested parties have applied to the court to join the case as respondents. These include the Council for Medical Schemes, Hospital Association of South Africa, South African Private Practitioners Forum, Multiple Sclerosis Society of South Africa and Infertility Awareness Association of South Africa. The court heard all these parties on Thursday 18 June 2015.

PMBs paid for by medical aid schemes

The PMBs are a defined set of benefits aimed at ensuring all medical scheme members have access to certain minimum health care services, regardless of the benefit option they have selected. PMBs include chronic illness such as asthma, diabetes, epilepsy, as well as all emergency medical conditions. The costs of diagnosis, treatment and care of PMB conditions, including HIV, TB, and several mental health conditions and cancers must be paid in full by medical schemes. This means that the patient does not have to pay out-of-pocket or out of their Medical Savings Account for these conditions. The objective is to provide for with continuous care and ensure that members do not run out of benefits for the specified medical conditions. This is meant to protect the right of everyone to have access health care services.

TAC, SADAG and PLWC believe that the Minister does have the power to regulate the medical schemes by requiring the payment of PMB conditions in full and without co-payments or deductions. They argue that patients’ right to have access to health care services is key to determining this challenge. They are represented in this matter by Section27.

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