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Victory for patient care

01 March 2016 - 02:27 By Katharine Child

Private patients cannot be forced by their medical schemes to go into state hospitals for the treatment of diseases listed as prescribed minimum benefits. The Constitutional Court has dismissed an appeal by Genesis Medical Aid after it refused to pay for three prosthetic devices for a patient with a broken leg unless they were provided by a state hospital.The dismissal ends the legal battle between the scheme and the Council for Medical Schemes over the treatment of PMB conditions.The treatment of PMBs - which cover 300 diseases and emergency care - should by law be covered in full by private medical schemes.A broken leg is listed as a PMB.Genesis argued that, according to its rules, which the regulator had approved, devices for the broken leg had to be obtained at a state hospital.Genesis argued that when treatment for PMBs were to be paid for in full, it gave doctors a "blank cheque" to charge what they liked.This was unsustainable for medical schemes and led to an increase in premiums, Genesis argued.The Supreme Court of Appeal ruled against Genesis' refusal to pay for the devices.The court ruled that PMB diseases were to be paid for in full as the law was designed to give medical aid scheme members a certain level of coverage and ensure private patients did not burden state facilities.The Constitutional Court dismissed the Genesis appeal without a hearing because it stood a "limited chance of success"."This is undoubtedly a momentous judgment in that it settles once and for all the ongoing speculation by medical schemes on limiting prescribed minimum benefits," said Council for Medical Schemes registrar Daniel Lehutjo.In a separate legal matter, Genesis is currently asking the Cape Town High Court to strike down the regulation that prescribed minimum benefits conditions must be paid in full no matter the cost.The Department of Health, a respondent in the matter, is not opposing the application...

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