This is a Ruling of the Council for Medical Schemes Appeals Committee, a Specialist Tribunal that determines medical aids or schemes disputes between medical aid members or beneficiaries and medical schemes, or between medical service providers and medical schemes, or between medical schemes and the Registrar of Medical Schemes.

The case concerns

  • what the appropriate procedure is when a member is aggrieved by a decision of a medical scheme’s internal dispute resolution committee; and
  • factors applicable in claims for Overseas Treatment Benefit

The member unsuccessfully claimed under the scheme’s Overseas Treatment Benefit for the treatment of her son’s condition (Spastic Deplegic Cerebral Palsy) in the United States on the ground that the procedure (Selective Dorsal Rhizotomy or SDR) is “not routinely available” in South Africa or is “not readily available” in South Africa or no one in South Africa is “experienced enough” to perform the medical procedure.

She then lodged a complaint with the scheme’s internal disputes resolution committee which dismissed her complaint. She had already spent over US$44,000 in the United States for a procedure for which the scheme covers up to R500,000.

From there she was advised, incorrectly, to lodge an appeal directly with the appeals committee of the Council for Medical Schemes under s48 of the Medical Schemes Act, 1998 (the MSA), instead of s47 of the MSA.

Despite this procedural lapse, and the lateness of the appeal, the appeals committee decided to determine the matter on its merits because of the importance of the issue that arose.

The lesson in this case is the importance of reading and understanding the applicable medical scheme rules and benefit option provisions before embarking on costly medical interventions overseas.

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