Medical aid to cost more

Medical aid premiums will soar unless doctors and hospital fees are regulated, the Board of Healthcare Funders has warned.

While medical schemes are forced by law to "pay in full" for the treatment of 25 chronic conditions and about 270 medical conditions on the list of prescribed minimum benefits, they say that, without cost control, specialists will continue to "make hay while the sun shines" and charge whatever they wish.

Board spokesman Heidi Kruger said: "The more money that goes out [in doctors' bills], the more money has to come in."

A year after the board went to the Pretoria High Court to seek clarity on the meaning of the Medical Schemes Act wording "pay in full", they say they are now "back at square one".

On Monday, Judge Cynthia Pretorius dismissed the case - which was opposed by the Council for Medical Schemes, SA Private Practitioners Forum, Mediclinic, ER24 and the Hospital Association of SA, among others - on the basis that the board, which represents some medical aid schemes, did not have the right to bring the dispute to court.

The council, the industry regulator, hailed the ruling as a victory for consumers whose medical aids will have to continue to "pay in full" for the full list of prescribed conditions, including asthma, diabetes, HIV, hypertension, epilepsy, coronary artery disease and bi-polar mood disorder.

Council CEO Dr Monwabisi Gantsho said: "At the end of the day, this is the law - pay in full means pay in full."

He said the board did not prove that service providers were overcharging and, without this evidence, medical schemes had no reason to raise their premiums.

But the board lashed out at the council yesterday, saying they were "gloating" about the court ruling, which is an unresolved "consumer issue".

"We are going to see more reckless and opportunistic charging by providers," Kruger said.

However, the Department of Health's Dr Anban Pillay said the board was predicting a "worst-case scenario" whereby doctors would charge whatever they wanted. Pillay said the minister of health would soon make an announcement about escalating private healthcare costs.

The board's deputy chairman, Tom Borrill, said it will appeal the ruling.

Recounting a personal experience, Borrill said that his wife's pulmonologist (a respiratory specialist) had billed them R2125 for each of 20 hospital consultations over 10 days.

"He'd walk in, check her pulse rate, read the chart, and submit the bill. Then he'd do the same thing in the afternoon," said Borrill.

"The member is going to suffer. The only way we can protect them again is by putting up the rates," he said.

The board has been ordered to pay the legal costs of the 13 respondents represented by seven legal teams, which the board's managing director, Dr Humphrey Zokufa, estimated to be about R7-million.