PMBs must be paid in full – Medical Chronicle
November 8, 2011 @ 5:16 pm
posted by Deon

Prescribed Minimum Benefits (PMBs) must be paid in full. This was the ruling handed down this morning by the Gauteng High Court after the Board of Health Care Funders of Southern Africa (BHF) and the South African Municipal Workers Union National Medical Scheme approached the court asking for a declaratory order on the interpretation of the words “pay in full” as in appears in Regulation 8 of the Medical Schemes Act.

BHF sought to convince the court that “pay in full” should be interpreted as meaning “pay in full” according to the rules of the medical scheme and not “pay in full” as per invoice. The motion was opposed by the Council for Medical Schemes (CMS), the SA Private Practitioners Forum (SAPPF) and 11 other stakeholders.

In her ruling Judge Cynthia Pretorius said the court was asked to decide on three issues; namely the first applicant’s entitlement to institute proceedings for declaratory relief, the interest and locus standi (legal interest) of the intervening respondents in opposing the relief sought by the applicants; and the meaning of the words “pay in full” as set out in Regulation 8 (1) of the general regulations which were promulgated in terms of section 67 of the Act.

In terms of its entitlement to institute proceedings, Judge Pretorius said the fact that not all medical schemes were represented by the BHF rendered the application “fatally defective”.

She found that it was not true that the BHF represented 75 medical schemes and seven medical administrators as claimed in their application, but in fact only represented 15 registered medical schemes.

The first applicant’s application is lacking in allegations and proof that it has any mandate to litigate on behalf of its members, said Judge Pretorius.

She found that the applicants therefore did not have a legal interest in the application and that the court thus did not have to deal with the application. She dismissed the application with costs.

In a statement issued shortly after the ruling was handed down, Dr Monwabisi Gantsho, registrar and chief executive of the CMS, said they were delighted with the outcome.

“PMBs are a cornerstone of the Medical Schemes Act and they were included in legislation for a good reason: to protect beneficiaries against unforeseen ill health that may prove financially catastrophic for them. As the regulator tasked with looking after the best interests of medical scheme beneficiaries, we are happy that our courts have confirmed the need for such protection in law”, he concluded.