Medical Scheme Challenges PMBs in Court

A South African Medical Aid Scheme is challenging the prescribed minimum benefits (PMB) legislation that requires full medical aid coverage of PMBs, regardless of cost.

Genesis Medical Scheme has filed papers against the Minister of Health, Aaron Motsoaledi, charging that the legislation costs medical aid schemes too much. This, the scheme claims is harmful to consumers because it has resulted in increased member contributions. Genesis claims that if the legislation is not changed, medical aid scheme tariffs will escalate to a figure very few people will be able to afford.

At present, basic PMBs cover 26 chronic diseases as well as emergencies that are life threatening and 270 other medical conditions. All of these must be covered in full by medical schemes, irrespective of the type of cover or plan members opt for.

Medical Scheme PMBsGenesis argues that those who understand the PMB law often buy cheaper medical aid cover, especially those who are young and healthy. The medical scheme claims that only very sick people or those who are ignorant pay for more expensive plan options. Further, they claim that specialists are able to “manipulate costs” specified to treat conditions and diseases covered in the PMB list.

This is confirmed in the papers by Christoff Raath who stated that some specialists do indeed charge “significantly more” for listed PMBs than for conditions that are not on the prescribed list. Joint CEO of Insight Actuaries, Raath said it wasn’t illegal for medical doctors and specialists to charge more, but the fact that their costs would be fully covered removed any incentive for them to negotiate prices with medical schemes to lower member costs.

At least one outraged patient group has stated it will challenge the court application, claiming that chronically ill patients will lose their medical cover and also be denied life-saving care and treatment if the legislation is changed.

Kelly du Plessis, founder of the Rare Diseases Society of SA is also furious that the court application, filed in June 2014, has only just been made public as her NGO now has only a couple of weeks to respond to the application.
Even though the Society is not a respondent in the case, Du Plessis says it plans to represent patients because they stand to lose medical cover and protection.

Genesis Medical SchemePMBs currently ensure that members of medical schemes have access to quality medical and health care for life-threatening conditions all the time, she said. If PMB cover was capped, this would impact on patients. For example, if treatment for diabetes was capped at R50 000 per year, anything over and above this figure would have to be paid for by the patient.

Recent submissions made to the Competition Commission indicate that although cases of straightforward depression are on the decrease, there has been an increase in the number of claims for condition like bipolar disorder. Medical schemes claim that this is because PMBs do not cover “depression”, but they do cover bipolar disorder.

It is argued that medical aids charge members R518 monthly, on average, just to cover the PMBs. This in turn indicates that membership can’t cost any less that R600 (including any administrative costs).

The principal officer of Genesis, Brian Watson has declined to comment on the matter. However, it is known that the Board of Healthcare Funders, a representative of several medical aids, attempted to have the PMBs “struck down” in 2011. The attempt was unsuccessful, due to a technicality.