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Court ruling in favour of CMS – Creates precedent for medical schemes

A court ruling has empowered consumers to force their medical aids to fund any drug or medical care a doctor considers necessary to treat any disease that falls under the “Prescribed Minimum Benefits” (PMB.

Business Day reported that the Council for Medical Scheme’s ruling followed the case of a glaucoma patient who took on Discovery Health Medical Scheme over its refusal to pay for an implant that was recommended by a specialist. The scheme, which would have paid for a treatment more than two times what the device would have cost, argued that clinical evidence on the effectiveness of the stent was weak, and that it was legally entitled to refuse payment for it as it was not offered in state hospitals.

Kieno Kammies of Cape Talk radio interviewed Thembekile Phaswane (Senior Manager, Council for Medical Schemes) and Dr Tim Modupe (Head of Clinical, Council for Medical Schemes) as a result of this ruling to better understand the importance of the ruling as well as the precedent now created for clients of medical schemes in general.

Click here to listen to the interview.

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