Medical aid battle

Medical aid members could find their cover reduced if a legal battle to have prescribed minimum benefits capped is successful.

Currently, these basic benefits, which cover 26 chronic diseases, 270 other conditions and life-threatening emergencies, are covered in full by medical schemes.

But* Genesis Medical Scheme has taken Minister of Health Aaron Motsoaledi to court to have the regulation requiring cover of prescribed minimum benefits - irrespective of the cost - struck down.

Outraged patient groups intend to challenge the application in court, saying the chronically ill will lose medical cover and be denied life-saving treatment if the law is changed.

The medical aid argues, in papers filed in the Cape Town High Court, that the legislation is costing medical schemes too much and leading to increases in member contributions that have hurt consumers.

The scheme fears that if the law is not changed, costs will escalate to such a degree that "only a few people" will be able to afford medical aid membership.

In addition, they argue that some medical specialists manipulate costs for treatment of conditions covered by the prescribed minimum benefits.

Christoff Raath, joint CEO of Insight Actuaries whose analysis is cited in the court papers, says some specialists charge significantly more for such procedures than for illnesses not covered by the minimum benefits.

Raath said it was not illegal for doctors to charge what they wished for treatment of these conditions, "but the law that their costs will be covered in full removes the incentive for doctors to enter into price negotiations with medical schemes and negotiations on price are needed to keep costs down".

In terms of the law, every medical aid member, irrespective of their type of cover, is entitled to prescribed minimum benefits.

The medical aid argues that people who understand the law buy cheaper cover, especially if they are younger and healthier, and only the ignorant or very sick pay for the more expensive options. This, they say, is not sustainable.

The founder of the Rare Diseases Society of SA, Kelly du Plessis, is outraged that the court papers, which were filed in June last year, have become public only now, leaving the NGO just over two weeks to respond.

The organisation is not cited as a respondent in the court papers but says it wants to represent patients it believes will lose protection and medical cover.

"Prescribed minimum benefits ensure patients receive access to quality healthcare for life-threatening conditions all year round," Du Plessis said.

Capping the cover would reduce access to the quality of healthcare individuals currently enjoyed.

Du Plessis said if the law were changed, the costs of treatment for a diabetic currently fully covered could be capped at R50000 a year, for example. If their treatment exceeded that amount, they would have to pay from their own pocket.

Recently, submissions to the Competition Commission showed that though cases of ordinary depression were decreasing, the number of claims being made for conditions such as bipolar disorder were increasing. Medical aids argue that this is directly linked to prescribed minimum benefits because these do not cover depression but do include bipolar disorder.

This, they argue, shows that some doctors are misdiagnosing conditions to ensure the costs of patients, who might be cash- strapped, are covered in full.

In order for medical aids to cover the prescribed minimum benefits, every member pays an average of R518 a month. This means membership cannot cost less than about R600 a month (including administration costs).

Genesis principal officer Brian Watson declined to comment.

The Board of Healthcare Funders, which represents some medical aids, tried to get the benefits struck down in 2011 but was disqualified on a technicality.

*Correction: Previously the story said the SA Municipal Workers' Union Medical Aid was part of the legal action, however they have withdrawn from it.