Court battle over medical aid bid to cut patient benefits

19 June 2015 - 11:23 By Katharine Child

The Department of Health is intending to change the regulation that ensures certain diseases are paid for no matter the cost by medical aids. At the same time‚ a court case over the regulation began in the Western Cape High Court on Thursday.Currently‚ the Medical Schemes Act ensures that prescribed minimum benefits cover 26 chronic diseases‚ 270 other conditions and life-threatening emergencies‚ and have to be paid for “in full” by medical schemes.This protects consumers and ensures they don’t run out of funds for certain diseases halfway through the year.These PMB (prescribed minimum benefits) conditions include HIV‚ emergency conditions‚ TB‚ diabetes and rheumatoid arthritis.Before PMBs were made law‚ patients with chronic diseases like diabetes would run out of funds for monthly treatment halfway through the year. Now they get treatment.Genesis Medical Scheme has asked the court to change the regulation that ensures PMBs are paid for in full. The scheme is arguing that the fact certain diseases are covered no matter the cost leads to high doctors' and hospital charges‚ which strain medical aids and up monthly premiums. This means fewer people will be able to afford medical schemes in future‚ argues the scheme.Data does show that some doctors overcharge for procedures that are prescribed minimum benefits as they know their fees will be paid in full no matter the cost. There is no regulation on what doctors can charge.Genesis wants the benefits capped.The health minister was cited as the only respondent in the case‚ but he did not oppose the Genesis application to change the law and reduce medical aid benefits. Essentially this means the minister is not arguing against the medical aid's attempts to reduce benefits.This is a concern for health NGOs who represent chronic disease patients.Rare Disease Organisation founder Kelly du Plessis‚ whose organisation was made a friend of the court in the case yesterday‚ said: “Minimum Benefits are a fundamental aspect of our healthcare system in the private sector. We need to know that our interests are a priority to our Minister of Health‚ and the apparent lack of response from the minister is worrying".Du Plessis' son has a rare disease and needs his Prescribed Minimum Benefit to keep him alive. "With treatment costs in excess of R1 million per year‚ without continuous and appropriate access to Prescribed Minimum benefits‚ his chances for a good quality of life‚ would be minimal‚" she said. On Thursday‚ it emerged that the minister wants to change the law being contested in court. Health department spokesman Joe Maila said: “We have decided not to oppose the case because we are amending regulation 8 of Medical Schemes Act [ that ensures PMBs are paid for‚ no matter the cost]. The process of amending the regulations are at an advanced stage soon to be published for public comment".However‚ despite the fact the minister wants to change the law‚ many organisations are now involved in the court case.These include patient rights groups the SA Depression and Anxiety Group‚ People Living with Cancer and the Treatment Action Campaign‚ who went to court to be admitted as friends of the court and were successful.They say that the Prescribed Minimum Benefit law protects patients with chronic diseases.The TAC’s Anele Yawa explained: “The Treatment Action Campaign has always fought for affordable treatment for patients living with HIV and TB. The public sector is already over-burdened‚ with frequent stockouts of life-saving anti-retrovirals. Removing the PMB regulations will only further burden the public sector‚ where 5 million people currently access their treatment”. Cassey Chambers from the SA Depression and Anxiety Group said: “Many patients with mental health conditions will not be able to afford to pay or co-pay for the medicines they need and will land up in hospital with even more serious conditions”. The Hospital Association of SA‚ the SA Private Practitioners Forum and the Council for Medical Schemes‚ the Multiple Sclerosis Society of South Africa and Infertility Awareness Association of South Africa yesterday also asked the Western Cape High Court to admit them as respondents to defend the law that protects consumers. They want to oppose Genesis in the case. It is not yet decided by the court if they can act as respondents arguing against Genesis.The Council for Medical Schemes‚ the regulator of medical schemes‚ showed last year that these Prescribed Minimum Benefits cost R512 a month per member. The medical aid regulator's spokesman Elsabe Conradie said yesterday : "It is a concern that members will be prejudiced if mimimum benefits are capped".The case is continuing.

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