Profmed must pay for care, says court

December 8, 2011

Londiwe Buthelezi

Another milestone ruling has been made by the North Gauteng High Court regarding the payment of claims for major hospital events and related treatment by medical schemes.

Judge Justice Bam handed down judgment saying that Profmed must pay for in-hospital treatment as well as treatment after the member’s discharge from hospital where continued post-hospitalisation treatment is clinically indicated.

Last month the North Gauteng High Court defended the orders of the Council for Medical Schemes (CMS) in which the regulator told Profmed that treatment could not be limited to hospitalisation even where scheme rules provided for benefits “only directly after” a medical emergency.

The court later confirmed the regulator’s assertion that Profmed must cover post-hospital treatment.

The CMS imposed an administrative penalty on the scheme in July last year.

Profmed paid all in-hospital claims submitted by scheme member Henri Francois Junod, whose wife was involved in a car accident in 2005. When she was discharged in 2006, she still needed physiotherapy.

According to benefit rule 1E4 of Junod’s medical aid option at the time, he and his dependants were covered in the case of temporal disability as a result of acute injuries, but rehabilitation was only available directly after an incident.

Profmed argued these were the key words of rule 1E4.

Handing down his judgment, the judge said he was not persuaded that the registrar of medical schemes and the CMS were wrong in ruling that the benefits provided for in terms of rule 1E4 extended beyond in-hospital treatment.

“Not even one word used in drafting rule 1E4, to my mind, suggests that the benefit does not cover treatment after discharge from hospital. The argument on behalf of the applicants (Profmed) in which the words ‘directly after the traumatic experience’ are emphasised, should not be understood as to limit the period in question to only treatment in hospital,” said Judge Bam.

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