A recent judgment of the Supreme Court of Appeal, brought to my attention by one of my staff, has quite interesting implications for many members of Medical Aids.  This involved a Medical Aid by the name of Genesis Medical Scheme who refused to pay for certain treatment where the client received that treatment in the private sector or essentially a private Clinic.  This was one of the specific medical conditions that is listed in the table as to the prescribed minimum benefits that Medical Aids have to provide in South Africa and the Medical Aid tried to get out of that by saying that the member bound itself to their rules and their rules did not provide for that in this particular case.  

Genesis argued essentially that by agreeing to its rules its members agreed that the full benefits that are prescribed in the Act must be regarded as being waived by its members.  The court said that individuals can waive their rights in some cases, but not in a case where public policy requires the observance of the law, because then the individual that would be waiving their rights is not the only person interested in those rights – there is the community and society at large who are affected by the person “waiving” their rights.  They pointed out the legislation in this kind of case was specifically there to assist people who are bargaining from an inferior position and as the court held, "Simply put, the law obliges Medical Schemes to pay the costs of treating PMB conditions in full, and that is what Genesis must do."  The Court was not happy that Genesis was simply trying to hand the burden of dealing with such treatment off to the state.  The court, in fairly strong language, said that if Genesis wants to carry on the business of a Medical Scheme, then it has to supply the benefits required in terms of the Medical Schemes Act.  The worst part is that this is a case that Genesis fought, not only with the Registrar of Medical Schemes where they lost twice, but then took it to the Western Cape High Court where they finally had some success before losing on appeal.  The case was brought against Genesis Medical Scheme by the Council for Medical Schemes as well as the Registrar of Medical Schemes and it is good to see that they took an interest in such a case and that this Medical Aid has learnt the lesson that you cannot simply invent your own regulations and try to ignore the laws of the land.