by Londiwe Buthelezi
The Council for Medical Schemes (CMS) was in the process of deregistering a medical scheme that had deliberately not complied with Regulation 8 of the Medical Schemes Act, which relates to the payment of prescribed minimum benefits (PMBs), the regulator said last week.
The registrar of medical schemes and chief executive of the CMS, Monwabisi Gantsho, said some medical schemes had indicated that they would not abide by the regulator’s interpretation of Regulation 8, which says that schemes must pay for the diagnosis, treatment and care of all prescribed conditions “in full”, or at the price charged by the health-care provider. However, many had since agreed to comply with the CMS’s interpretation.
The North Gauteng High Court ruled earlier this month that treatment for all of the nearly 300 PMB conditions listed in the Medical Schemes Act must be paid in full at the price charged by the health-care provider and not “in full” in terms of scheme rates, as schemes had contended.
After this ruling, Gantsho promised that the regulator would act against schemes that had been non-compliant and against their administrators.
The CMS said its complaints adjudication unit received 5 617 complaints in the 2010/11 financial year. It said the number of complaints reaching this unit had been increasing every year.
But Gantsho said that not all complaints relating to PMBs necessarily translated to the contravention of Regulation 8.
“The member could have voluntarily used a non-designated service provider, which means that the scheme had acted within its rights by imposing a co-payment or paying related claims at the scheme rate and not in full. In other instances the scheme will realise that they made an error and pay the claims in full after a complaint would have been lodged,” he said.
Nevertheless, he said there were schemes that deliberately did not pay full PMB benefits.
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