Medical aid: minimum benefits to stay

8 November 2011

Prescribed minimum benefits – the minimum level of diagnosis, treatment and care that a medical scheme is obliged by law to cover – will remain in place in South Africa following a Pretoria High Court ruling.

“We are delighted with this ruling,” registrar of medical schemes and CEO of the Council for Medical Schemes, Monwabisi Gantsho, said after Monday’s ruling.

The law which prescribed minimum benefits would stand, the council – the first of 13 respondents in the matter – said in a statement.

The ruling came after the Board of Healthcare Funders of SA (BHF) challenged regulation eight of the Medical Schemes Act 131 of 1998 and asked the court to pronounce on it.

BHF represented a number of medical schemes and administrators and was later joined by the SA Municipal Workers’ Union national medical scheme.

Regulation eight states that medical schemes must pay for the diagnosis, treatment and care of all prescribed minimum benefits conditions in full, or at the price charged by the health care provider.

Prescribed minimum benefits are the minimum level of diagnosis, treatment and care that a medical scheme is obliged by law to cover.

The scheme must pay for all prescribed minimum benefit conditions in full and from its risk pool, not from a clients’ savings account.

These benefits include 270 serious health conditions such as tuberculosis and cancer, any emergency condition, and 25 chronic diseases, including epilepsy, asthma and hypertension.

“Prescribed minimum benefits are a cornerstone of the medical schemes act and they were included in legislation for a good reason: to protect beneficiaries against unforeseen ill health that may prove financially catastrophic for them,” Gantsho said.

“As the regulator tasked with looking after the best interests of medical scheme beneficiaries, we are happy that our courts have confirmed the need for such protection in law.”

Sapa