Open Letter from Genesis Medical Aid March 2016
At Genesis, we believe that the scheme is its members and the members are the scheme. Therefore, decisions taken by the Board of Trustees and the actions taken by management must be fair, transparent and in the interest of all members.
You may have read in the press of a recent Supreme Court of Appeal judgement forcing Genesis to fund an external prosthetic device for a member who was not entitled to that benefit according to the Rules of the scheme.
The Court’s judgement, with which Genesis does not agree, has created certain difficulties in that the Supreme Court has seemingly gone against one of its earlier judgements in the Sechaba matter and held that the Rules of a medical scheme are not necessarily binding on members.
As a result of this judgment the scheme has been forced to fund these prosthetic devices out of member funds which were not originally allocated to these benefits, thereby utilising funds which may have been used for the benefit of members whose conditions do fall within the Rules of the scheme.
The Medical Schemes Act permits medical schemes to select Designated Service Providers (DSP) to provide Prescribed Minimum Benefits (PMB) to members. In fact, the Supreme Court criticised Genesis for not appointing a DSP in the case that it judged.
Therefore, Genesis has with immediate effect selected every hospital in the public sector as its DSP for the treatment of the PMB.
Please be assured that this does not affect your benefits in any way and that all benefits remain unchanged. It simply means that when a PMB condition is treated in a public sector hospital, the claim will be reimbursed in full.
When the condition is treated in a private sector hospital, the limits set out in the Rules will apply. Your private hospital account will usually be settled in full and only in circumstances where a doctor charges more than 100% or 200% of the scheme rate (depending on your particular benefit option) will you be liable for any shortfall.
It is important to remember that the Consumer Protection Act provides further protection to members by stating that every doctor must, by law, discuss his charges with you, which enables you to then check with Genesis as to the level of reimbursement you are entitled to.
An example which perfectly highlights what is said above is a recent case where a member on the Private Choice option, with a monthly contribution of R950 (currently), was treated for a PMB condition in a private hospital. After paying just R25 000 in contributions since the member joined the scheme, Genesis settled claims totalling some R600 000, as the hospital and all of the doctors charged the scheme rate of 100% or close to that rate.
This case also highlights the cross-subsidisation principle which applies to all medical schemes, where the funds are pooled and paid out according to the needs of the members. That way, members are assured that when they are taken ill or are involved in an accident and require medical intervention, there will be sufficient funds in the pool to pay for those services on the basis set out in the Rules.
As a result of prudent management of the scheme and responsible claiming patterns by most of its members, Genesis has been able to contain premium increases to a minimum for the past several years whilst still enhancing benefits. To this end, we assure you of our ongoing commitment to protect the best interest of all members of the scheme.
We would like to reaffirm our pledge to providing you, our member, with open and honest communication. We trust that you will understand the need for this change and invite you to engage with us should you require clarification or explanation on this or any other scheme related matter.
Dennis van der Merwe
Issued: 12 March 2016