High court pronounces on medical scheme rule

December 14, 2011

The High Court in Pretoria has ruled on the correct interpretation of a rule of a medical scheme.

Last month the North Gauteng High Court upheld the directives of the Council for Medical Schemes (CMS) in which the regulator tells Profmed Medical Scheme that treatment cannot be limited to hospitalisation even where the rule of the scheme provides for benefits “only (…) directly after” a medical emergency.

The court confirmed the regulator’s assertion that Profmed must cover in-hospital treatment as well as treatment after the member’s discharge from hospital where continued post-hospitalisation treatment is clinically indicated.

“The Council for Medical Schemes is once more vindicated by our courts to continue protecting members and beneficiaries of medical schemes,” said Dr Monwabisi Gantsho, Registrar of Medical Schemes and the Chief Executive of the CMS. “I am glad that the courts are assisting the CMS in enforcing the law without fear or favour. Members of medical schemes are entitled to good quality care and should have access to comprehensive healthcare in terms of the scheme rules as approved by the CMS.”

The ruling can be found on the CMS’s website (www.medicalschemes.com) or at the following ~ulink#www.medicalschemes.com/files/Judgements%20on%20Appeals/Profmed_vs_Registrar_n_CMS_n_%20J.pdf~

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