LegalBrief Today commented as follows on the outcome of the Scheme’s application for leave to appeal against an SCAS finding.
In what a Business Day report says is a decision that has far-reaching implications for medical scheme members, the Constitutional Court has dismissed Genesis medical scheme’s application for leave to appeal against a SCA judgment last year, upholding the supremacy of the Medical Schemes Act over the rules of individual schemes. The SCA ruled that medical schemes could direct patients to state hospitals for treatment for Prescribed Minimum Benefits (PMBs) only if they had put designated service provider contracts in place. Genesis had not set up contracts with the state, and had refused to pay for three external prostheses for a member with a broken leg fitted in a private hospital.
The court said the rules of a medical scheme could not be seen in isolation, and Genesis could not contract out of the obligations set out in the Act, which required it to pay in full for prescribed minimum benefits. It said the Act gave Genesis the opportunity to manage its liabilities for payments for PMBs by appointing designated service providers, but it had failed to do so, and so was obliged to pay for the member’s prostheses.