Threat to medical aid basics

The Health Department is considering changing legislation that requires medical aid societies to pay for the treatment of certain medical conditions in full - irrespective of how much the service provider charges.

A leading health economist, Wits professor Alex van den Heever, says that if the government does change the law it will be abdicating its responsibility to protect medical aid members and will be "protecting big business at the expense of the vulnerable and sick".

The regulation the Health Department is considering changing became law in 2004 and was intended to ensure that medical aid members got basic medical cover.

It states that the schemes must reimburse members in full for the costs of all emergency medical treatments, and for treatment of 26 chronic diseases and 270 conditions.

This clause, the subject of two court cases, protects consumers such as diabetics who previously often exhausted cover for monthly medication halfway through a year.

Van den Heever said the law had forced schemes to pay for chronic medicines and so they had negotiated with pharmaceutical companies to drop drug prices.

The proposed change in the law, Van den Heever said, would remove the incentive for schemes to negotiate with suppliers of medical services for better prices.

It would also mean patients might be left responsible for large co-payments for emergency treatment.

The Board of Healthcare Funders, representing medical aid schemes, has lobbied government to review the law.

The board argues that you cannot have benefits paid for in full - regardless of the cost - if there are no tariffs limiting what doctors can charge.