PMB claims: BHF to fight on

The Board of Healthcare Funders (BHF) plans to continue its legal challenge over your medical scheme’s obligation to pay prescribed minimum benefit (PMB) claims at full cost.

The BHF, which represents medical schemes and their administrators, has been denied leave to appeal a court’s decision not to provide legal clarity on a regulation under the Medical Schemes Act that states that schemes must pay PMB claims in full regardless of what a health provider charges.

However, the organisation now plans to appeal against the decision in the Supreme Court. It also plans to launch another court application that will deal with the merits of the PMB regulation, BHF spokesperson Heidi Kruger says.

The North Gauteng High Court ruled in November last year that the BHF did not have legal standing (locus standi) to ask the court to clarify the PMB matter. The court said the BHF had no material interest in the declaratory order it was seeking.

Judge Cynthia Pretorius said the medical schemes affected by the PMB regulation should have brought the court application jointly.

A medical scheme for municipal workers, Samwumed, joined the BHF’s application for a declaratory order, but the judgment was silent on Samwumed’s status as a co-applicant, the scheme said this week. Samwumed plans to join the BHF’s appeal to the Supreme Court.

BHF managing director Dr Humphrey Zokufa says the BHF believes it does possess the necessary interest and standing to seek the relief it did.

The BHF also believes the court order was flawed in that the majority of opposing parties were also representative organisations, Zokufa says.

The BHF has also obtained legal opinion that emphasises the constitutional right to access the courts and the rights of representative bodies to approach a court on behalf of their members. The BHF believes the North Gauteng High Court has not thoroughly considered these rights, he says.

Medical schemes say the regulation that obliges them to pay PMB claims in full gives them an open-ended liability for these claims and gives healthcare providers the freedom to charge what they like for PMBs knowing that your scheme will have to pay. Schemes are of the view that the unlimited liability means they will be unable to contain the costs of claims and ultimately the contributions you pay.

The Council for Medical Schemes, which opposed the BHF’s application, says the PMB regulation protects you from ill-health leading to financial catastrophe, because your medical scheme is obliged to pay your PMB claims and you cannot be held liable for any part of the bill.