Docs challenge medical aid

13 August 2015 - 02:04 By Katharine Child

A medical aid scheme that has gone to court in an attempt to reduce the amounts it pays for the treatment of conditions on which no benefit limit is imposed can afford to pay the uncapped benefits, a group of doctors claimed yesterday. The SA Private Practitioners' Forum, a group of specialist doctors, is in a court battle with Genesis Medical Scheme.The scheme has asked the court to strike down regulations that force medical aid schemes to pay "prescribed minimum benefits" in full, regardless of what doctors and hospitals charge.These minimum benefits are payable for the treatment of 270 diseases, 26 chronic conditions and life-threatening emergencies.The Genesis website states that the regulations allow hospitals and doctors to charge whatever they like to treat these conditions. Genesis saysd that the situation is not sustainable.But the doctors said the scheme's financial statements show that it is not being subjected to "ruinous claims" for the conditions.The forum said the fact that the scheme's reserves were 540% higher than the legal requirement showed that it was "not exposed to potential bankruptcy due to uncontrolled expenses".Genesis told The Times it was fighting for the industry but would fight in court, not in the media.The forum said there was little "tangible evidence" that hospitals and doctors were exploiting the "payment in full" provision.They pointed out that the law allowed medical aid schemes to control costs by getting patients to agree to use specified doctors or hospitals.The minister of health has not opposed the Genesis court application. Instead, a month ago, the Department of Health introduced a draft law that would remove payment "in full" from the regulations.The new law would have medical aids cover the minimum benefits based on a 2006 price list that doctors say is outdated.But the specialists' forum warned that, if the draft law were enacted, or Genesis won its case, consumers would have "limited access" to healthcare.The Board of Healthcare Funders' Humphrey Zokufa denied that the law would have an adverse effect on medical aid members."The principles captured in the amended version of the law do not limit patients' benefits," he said.Prescribed minimum benefits cost on average R512 per medical aid member per month...

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