The Decryption of “Pay in Full” in terms of the Healthcare Schemes Act

  • SumoMe

During the latest case of the Board of Healthcare Funders of Southern Africa v Council For Medical Schemes 2011 JDR 1471 (GNP), the first and second applicants approached the judge by way of a demand to issue a declaratory order with regards to the explanation of the phrase “pay in full” in regulation 8(1) of the General Regulations made pursuant for the Medical Schemes Act, 131 of 1998.

The candidates fought that the Court was required to decide three issues, which is: 1. The first applicant’s right to commence actions for declaratory relief; 2. The interest and locus standi of the intervening respondents in opposing the relief sought by the candidates; and 3. The concise explanation of the terminology “pay in full” in regulation 8(1) of the General Regulations that had been promulgated with respect to section 67 of the Act.

Regulation 8 has been in force since 1 January 2000. In accordance with the candidates, the current problem begun on 11 November 2008 when the Appeal Board decided two cases on appeal which were referred by the Appeal Committee in terms of section 50 of the Act. The Appeal Committee as well as the Appeal Board had, pursuant to those two decisions, considered the phrase “pay in full” in regulation 8 to mean that the healthcare scheme need to make 100 % settlement of the service providers’ invoice in respect of the expenses of providing heath care treatment services for Prescribed Minimum Benefits if you don’t take the guidelines of the medical scheme into consideration in dealing with any problems.

It was actually the applicants’ argument that “pay in full” signifies repayment in accordance with the guidelines of the Healthcare Scheme, while in accordance with the respondents, the decisions by the Appeal Board haven’t been questioned as yet and presently medical aid schemes are bound to this power while having to repay service providers’ invoices completely.

The primary claim via the participants could be that the first applicant didn’t have immediate and substantial interest in the application since the verdict will not have a visible impact on it. Although the first applicant contended it defended 75 licensed healthcare aid schemes and therefore had locus standi, a legal court discovered this to not be. It was because of the reason that the first applicant saw suitable to have the second candidate, who is an authorized healthcare aid scheme, amalgamated. Moreover, only 15 licensed healthcare schemes, within the starting and extra founding affidavits, verified that a declaratory order ought to be found.

The Judge held that had the 1st candidate been so sure that it defended all 75 professional medical aid schemes it would not have been essential to join the other applicant or to receive affidavits and signatures of 15 members of the 1st candidate. A Legal Court concluded from this that the first applicant did not in fact represent 75 members, but only the 15 members stated in the paperwork.

The non-joinder of all of the professional medical schemes made the application fatally defective as the Courts could not discover that the primary candidate, as being a general representative of the professional medical schemes, can be prejudicially impacted by a judgment, but found that its participants may all be prejudicially influenced and consequently, many of the participants ought to have jointly implemented the request for the declaratory order.

The Judge found out that the initial applicant didn’t have locus standi for the reasons:

1. The matter was one which could be considered a representative matter, but not every one of the healthcare schemes had been amalgamated and it had not been started as a representative issue due to the fact that the first candidate was lacking any mandate to litigate on the part of all 75 of their associates;

2. In order to initiate action with respect to Section 38 of the Constitution, a litigant should show that a right enshrined inside the Bill of Rights has been encroached upon as well as adequate concern in the relief desired. The primary candidate didn’t expressly aver any such encroachment and the Judge found out that the First Complainant wouldn’t be directly influenced by the verdict and did not have a satisfactory concern in the relief sought.

With respect to the second applicant the judge held it will not be successful in the application by itself, as none of the alternative professional medical aid schemes or administrators ended up being connected.

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