SpesNews Volume 125
Genesis and PMBs in private sector
The Supreme Court of Appeal (SCA) in Bloemfontein upheld an appeal last week by the Council for Medical Schemes concerning prescribed minimum benefits (PMBs). The Scheme in question, Genesis Medical Scheme, opposed that it only had to reimburse for services rendered in the public sector as PMBs.
The difference in interpretation of the Regulation 8 provision was escalated to the CMS, who ruled that the scheme had to assume liability for the services rendered in a private facility. Not satisfied with this outcome, Genesis decided to escalate the matter to the Appeals Committee and ultimately to the Appeal Board (who supported the decision).
The scheme consequently approached the Western Cape High Court and lodged a review application against the Appeal Board on their decision. At which point, the Western Cape High Court agreed with the scheme and concluded that the registered rules of the scheme form a binding agreement between the scheme and its members.
The High Court further concluded that, since the CMS Registrar registers the rules of the scheme, he could not force the scheme to pay in full in terms of the Act without first issuing the scheme an instruction to amend its rules.
The CMS Registrar then lodged an appeal against this decision at the Supreme Court of Appeal since it believes that the provisions within the Medical Schemes Act always supersedes the registered rules of a medical scheme. The Supreme Court of Appeal then ruled in favour of the CMS Registrar. It found that the failure of the scheme to appoint a designated service provider (DSP) meant it could not refer to Regulation 8 (2) of the Act that deals with co-payment when a member receives services from a non-DSP. It also further noted that the scheme communication to its members misled the members into believing that a DSP had indeed been appointed by the scheme.
The verdict of the Supreme Court of Appeal signals a significant victory over the injustice members sometimes suffer at the hands of some medical schemes. This only comes weeks after Dr Johan Oelofse from SpesNet successfully lodged and won a complaint against the same medical scheme (Genesis) - quite a significant achievement in itself.
The verdict effectively also means that Genesis is expected to provide reimbursement for the management of PMB conditions in the public as well as private facilities.
PAIA still in the Spotlight
The Promotion of Access to Information Act (PAIA) gives effect to section 32 of the Constitution, which provides that everyone has the right to access information held by the State, as well as information held by another person (or private body).
PAIA provides that a person requesting information must be given access to any record of a private body, if that record is required for the exercise or the protection of a right. However, such request has to comply with the procedural requirements laid down by the Act.
PAIA requires private and public bodies to compile information manuals that will provide information regarding the types and the categories of records held by the particular body. To determine what records/ information is held by a body, their information manual can be requested.
The South African Human Rights Commission (the Commission) received notice on 26 November 2015 from the office of the Minister of Justice and Correctional Services confirming that the Minister has "decided to further exempt private bodies from compiling the Manual contemplated in section 51(1) of PAIA for a period of five years with effect from 1 January 2016." While still ungazetted, the notice of exemption will be made available by the Commission as soon as it has been published.
Practices who completed the online manual via the complymed.co.za website, are already compliant and will be able to update their manual at no cost. This would then be a legal requirement that they would not have to worry about going forward. SpesNet would still like to urge practices to not wait for the deadline before compiling their manual, as the current price of the manual is bound to change in a few years’ time.
Please visit www.complymed.co.za should you still require a PAIA manual for your practice. This is currently offered at a cost or R199 per manual. You also have the added benefit of having your PAIA manual submitted to the SAHRC in electronic format (please still arrange for a printed copy to be delivered at the SAHRC as well as having one available at the practice). Legal and technical support required to complete the manual are also included in this cost.