Tag archives: Medical schemes

Medical schemes cannot refuse to pay for single available treatment of a rare condition because it is not “prevalent”

By Anika de Kock and Paulette Khumalo on September 28, 2022 Posted in Healthcare

MD and Another v Medihelp Medical Scheme and Another [2022] ZAGPPHC 640 An urgent application was brought to the High Court by the mother of a three-year-old child (“Z”) who has been diagnosed with a rare genetic condition, Hunters Syndrome MPS II (“MPS II”). Z has been a member of the respondent medical scheme from … Continue reading

Jurisdiction of the Financial Services Tribunal: medical scheme matters

By Ntokozo Ngubane on July 9, 2020 Posted in General

A medical scheme aggrieved by a decision of the Registrar for Medical Schemes must appeal to the Council for Medical Schemes and not the Financial Services Tribunal, even if the decision relates, broadly, to financial sector laws. In Medihelp Medical Scheme v The Registrar for Medical Schemes and Another, the Council for Medical Schemes, instituted … Continue reading

COVID-19 and the potential use of medical scheme reserves

By Ntokozo Ngubane and Michelle David on April 16, 2020 Posted in General

Medical scheme trustees cannot take a business as usual approach during the COVID-19 pandemic. Boards should be giving thought to the value of their reserves and whether using such reserves would be of benefit to members. At a minimum, trustees need to understand the options available to them when considering using scheme reserves. In terms … Continue reading

Coronavirus and medical scheme benefits in South Africa

By Michelle David on March 10, 2020 Posted in General

Coronavirus is yet to test the rules of medical schemes. While it has been reported that a virus like COVID-19 would not usually be covered as a prescribed minimum benefit condition, where the virus amounts to an emergency condition then it will fall within the PMB legislation. In addition, to the extent that the virus … Continue reading

Laws amendment to accommodate demarcation regulations

By Patrick Bracher (ZA) on April 24, 2017 Posted in Insurance

The pending changes to the Medical Schemes Act and the Long-term and Short-term Insurance Acts to accommodate the demarcation regulations were made on 1 April 2017 including the new definition of ‘business of a medical scheme’. The definition of ‘business of a medical scheme’ in the Medical Schemes Act 1998 makes it clear that if you … Continue reading

Medical scheme member savings accounts are trust property

By Patrick Bracher (ZA) on June 13, 2016 Posted in General

Members’ funds allocated by medical schemes to their members’ savings accounts are trust property in terms of the Financial Institutions (Protection of Funds) Act 2001 (FI Act) and must be accounted for separately. Section 35(9)(c) of the Medical Schemes Act provides that the liabilities of the medical scheme must include the amounts standing to the credit of … Continue reading

Contracting out of legislative protection

By Donald Dinnie on February 4, 2016 Posted in General

The law obliges medical schemes to pay the costs of treating prescribed minimum benefit conditions in full. The Supreme Court of Appeal in The Council for Medical Schemes v Genesis Medical Scheme provides a useful reminder of when a party may waive rights conferred by law for their benefit. The Medical Schemes Act does not … Continue reading

PMB coverage in medical scheme rules is a matter of public policy

By Gareth Munnick on December 15, 2015 Posted in General

Medical scheme rules may have no application if they fail to fulfil statutory law. The relationship between medical schemes and their members is not only governed by the medical scheme rules but primarily by obligations imposed by statute. The public policy considerations taken into account in the Medical Schemes Act which give rise to prescribed … Continue reading

Draft Demarcation Regulations 2014

By Patrick Bracher (ZA) on June 29, 2014 Posted in Insurance

The second Draft Demarcation Regulations were published by National Treasury for comment. The draft regulations deal with the demarcation between insurance business and the business of a medical scheme. Here is our analysis of the draft regulations. Interested parties must comment by 7 July 2014. Comments must be sent to Ms Reshma Sheoraj at LTdemarcation@treasury.gov.za … Continue reading