Bonitas Medical Scheme v Member (Council for Medical Schemes Appeals Committee, 17 December 2015)

Medical Schemes have a right to fund medication or drugs that are on their list (formulary drugs) for given medical conditions. They also have a right to fund the less expensive, but just as effective, formulary drug as the other more expensive formulary drug.

There is no obligation in law for a medical scheme to fund a more expensive drug (whether that is a formulary drug or a non-formulary drug) simply because the member prefers the more expensive drug, or simply because the member’s service provider (or doctor) swears by the more expensive drug.

Where two clinically approved drugs for the treatment or management of a prescribed minimum benefit condition (such as Crohn’s Disease) are available, the one more expensive than the other, the medical scheme is entitled to fund the less expensive drug as long as it is not less effective than the other drug. It  matters not whether both drugs are on the medical scheme’s formulary list or not.

This ruling of the Council for Medical Schemes Appeals Committee (a statutory body set up in terms of the Medical Schemes Act to resolve disputes in the medical schemes space) gives a sense of the relevant factors when a member claims for payment of a specific drug that is not on the medical scheme’s formulary list in circumstances where there is another less expensive drug (also not on the medical scheme’s formulary list) that is proven to achieve the same purpose as the non-formulary drug without adverse effects on the member.

In this case, the medical condition in question is Crohn’s Disease, a prescribed minimum benefit condition. But these factors apply in respect of all prescribed minimum benefit conditions.

Read Full Judgment Bonitas-v-Member

By |2020-02-01T16:18:28+02:00Feb 1st, 2020|Judgements, Medical Schemes, Ngalwana judgements|Comments Off on Bonitas Medical Scheme v Member (Council for Medical Schemes Appeals Committee, 17 December 2015)

S v Discovery Health Medical Scheme (Council for Medical Schemes Appeals Committee, 11 April 2016)

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.

Read Full Judgment https://www.medicalschemes.com/files/Judgements%20on%20Appeals/SVsDiscovery_2_20160712.pdf

By |2019-08-03T08:11:37+02:00Aug 2nd, 2019|Judgements, Medical Schemes, Ngalwana judgements|Comments Off on S v Discovery Health Medical Scheme (Council for Medical Schemes Appeals Committee, 11 April 2016)

Scheme Data Services (Pty) Ltd v Myhill NO and Others (JR1456/06) [2008] ZALC 149; [2009] 4 BLLR 381 (LC) ; (2009) 30 ILJ 399 (LC) (5 December 2008)

T he case deals with the proper meaning of s 191(12) of the Labour Relations Act (before amendment) in the context of the jurisdiction of the Labour Court and/or the CCMA where one employee is retrenched. The case parts ways with an earlier judgment of the Labour Court which held that the CCMA has no jurisdiction to consider a case where a single employee is retrenched procedurally unfairly.

The approach in Scheme Data Services was subsequently endorsed by the Labour Appeal Court.

Read Full Judgement here

By |2019-02-08T12:13:11+02:00Feb 5th, 2019|Judgements, Labour, Ngalwana judgements|Comments Off on Scheme Data Services (Pty) Ltd v Myhill NO and Others (JR1456/06) [2008] ZALC 149; [2009] 4 BLLR 381 (LC) ; (2009) 30 ILJ 399 (LC) (5 December 2008)

Roselli v Derek’s Boerewors and Pie Mecca CC and Others (84979/2014) [2016] ZAGPPHC 1160 (7 December 2016)

T his case considers what a court’s options are when confronted with disputes of fact in motion proceedings.
It also highlights the mischief of launching motion proceedings in the hope that the matter will be referred to trial thereby stealing a march on other deserving cases instituted by way of action proceedings at the outset.
Read Full Judgement here

By |2019-02-08T12:13:23+02:00Feb 5th, 2019|High Court, Judgements, Ngalwana judgements|Comments Off on Roselli v Derek’s Boerewors and Pie Mecca CC and Others (84979/2014) [2016] ZAGPPHC 1160 (7 December 2016)

Omegalabs (Pty) Ltd v Medicines Control Council and Others (32570/2015) [2016] ZAGPPHC 1157 (7 December 2016)

T his case concerns judicial deference on matters that fall outside their area of proficiency. It posits that the determination of whether a product fits the definition of a “medicine” or a “medical device” is not simply an exercise in interpretation of a statute but rather entails a decision which involves a highly technical and evidence-laden evaluation of deeply contested medical and scientific matters.

The MCC is best equipped to perform that exercise, not a Court of law. In so finding, the case parts ways with 2 previous judgments of the Pretoria High Court which held in 2014 and 2015 that because similar products are classified as “medical devices” in other so-called “benchmark” countries, they must be taken as being similarly classified in South Africa too.”

Read Full Judgement here

By |2019-02-08T12:13:36+02:00Feb 5th, 2019|High Court, Judgements, Ngalwana judgements|1 Comment

Ninval Properties (Pty) Ltd v Minnaar; In Re: Ninval Properties (Pty) Ltd v Negota and Another; In Re: Laniyan v Negota and Another; In Re: Laniyan v Mathekga (07385/2013,18620/2013,25313/2013,25314/2013) [2013] ZAGPJHC 325 (2 December 2013)

O ften litigants use sequestration proceedings in order to achieve a result for which such proceedings (and the legislation regulating them) is not intended. This is one such case.

The case also considers the proper meaning of s 10 of the Insolvency Act, particularly in relation to the requirement that sequestration must, in the opinion of the court, be in the interests of creditors.”

Read Full Judgement here

By |2019-02-21T15:06:04+02:00Feb 5th, 2019|High Court, Judgements, Ngalwana judgements|Comments Off on Ninval Properties (Pty) Ltd v Minnaar; In Re: Ninval Properties (Pty) Ltd v Negota and Another; In Re: Laniyan v Negota and Another; In Re: Laniyan v Mathekga (07385/2013,18620/2013,25313/2013,25314/2013) [2013] ZAGPJHC 325 (2 December 2013)

Asrai, P v Council for Medical Schemes & Discovery Health Medical Scheme

R equirements for the termination of medical scheme membership on grounds of non-disclosure of material information by a member at the time of joining the scheme. Many people tend to advance as a defence when caught out that they had no intention of withholding the information from the scheme (typically a pre-existing medical condition) and that, in any event, because they have been dutifully paying their premiums or contributions to the medical scheme and the scheme has been accepting them, the scheme cannot terminate their membership for non-disclosure which it should have discovered long ago and not only when a substantial claim is lodged. This ruling explains that this is not a relevant consideration.

Full Judgment here

By |2019-02-08T12:10:47+02:00Feb 5th, 2019|Judgements, Medical Schemes, Ngalwana judgements|Comments Off on Asrai, P v Council for Medical Schemes & Discovery Health Medical Scheme

Pension Funds: Browne HC v SARAF & OMLACSA

This judgment deals with whether a member of a retirement annuity fund may transfer his membership to another RA before reaching retirement age.

Full Judgment here

By |2019-02-08T12:10:27+02:00Feb 4th, 2019|Judgements, Ngalwana judgements, Pension Funds|Comments Off on Pension Funds: Browne HC v SARAF & OMLACSA

Otto, H v Council for Medical Schemes & Discovery Health Medical Scheme

T his judgment deals with the vexed question of prescribed minimum benefits and how they work

Full Judgment here

By |2019-02-08T12:10:35+02:00Feb 4th, 2019|Judgements, Medical Schemes, Ngalwana judgements|Comments Off on Otto, H v Council for Medical Schemes & Discovery Health Medical Scheme
Go to Top