1) A provider of a service that has rendered any kind of service to a beneficiary with regards to which an account has actually been rendered, shall, in spite of the conditions of any other legislation, furnish to the user involved an account or statement highlighting such specifics as may be recommended by doctors; 2) A medical scheme shall, in the case where an account happens to be rendered, susceptible to the conventions of the Act along with rules from the medical scheme concerned, pay out to a member or supplier of service, any kind of reward due to that member or supplier of service within thirty days after the day by which the claim in regard of such bonus was received via the medical scheme".
The query takes place whether this section only permits medical schemes to pay companies directly or whether it in actual fact create a duty on medical schemes to make repayments directly to service providers, as has been contended by companies.
The Supreme Court of Appeal, in Medscheme Holdings (Pty) Ltd and the other v Bhamjee [2005] ALL SA 16 (SCA), discovered that Mr Bhamjee, a doctor, had no basis upon which to demand that Medscheme (an authorized medical scheme) pay him directly.
In this conclusion, the Court seemed to recognise that although section 59(2) makes a basis upon which medical schemes may expel obligations owed to customers by reimbursing service providers directly, the section doesn't oblige a medical scheme to take action when the provider had lodged an account with the medical scheme.
This viewpoint was affirmed in the fairly recently resolved and reportable matter of Tshwane Pharmacy (Pty) Ltd v GEMS that was heard by the North Gauteng High Court under case number 28532/11.
In this situation the Applicant (a service provider) applied to Court on an emergency basis for an order pointing that the Respondent (a registered medical scheme) generate payment directly to them, and not to their associates.
The Applicant fought that the key phrase in section 59(2) of the Act is "benefit due to the customer or provider of the service" which with a common sense understanding of the area it means that when a member has not paid the service provider of the service the medical scheme has no discernment but is required to repay the supplier.
A Legal Court failed to accept this discussion, and held that section 59(2) must be interpreted in context. Subsection (1) provides that the provider of a service who has rendered a service is obligated to furnish the member interested in an account comprising prescribed information. Subsection (2) then provides that when such an account has been rendered the medical scheme may pay to the member or the provider of the service the bonus owing to that member or supplier of the service.
The Court also held that, in the context of the section, the benefit yet to be paid must make reference to the amount owing by the member to the supplier for the services supplied. The Court mentioned that it's inconsequential that the benefit becomes due to the customer by virtue of the agreement concerning the customer and the medical scheme and, to the provider, thanks to the contract involving the member and the provider. The subsection does not build an obligation on the medical scheme to pay the supplier.
Moreover, the Court held that the subsection clearly provides that payments is subjected to the guidelines of the medical scheme, and in the case of the Respondent it's regulations stated unambiguously how the Respondent has the right to pay either the customer and the supplier of the service.
Consequently, the Court identified no basis for a duty on the Respondent to pay the Applicant directly and laid off the application along with costs.
From the above it's very clear that to assure repayment for services rendered by service providers ought to either claim payment from their patients, or make sure that they've contractual agreements with the medical schemes. Right now, our Courts seem unwilling to demand a legal responsibility on medical schemes for making payments directly to companies even without this kind of contractual arrangement.
The query takes place whether this section only permits medical schemes to pay companies directly or whether it in actual fact create a duty on medical schemes to make repayments directly to service providers, as has been contended by companies.
The Supreme Court of Appeal, in Medscheme Holdings (Pty) Ltd and the other v Bhamjee [2005] ALL SA 16 (SCA), discovered that Mr Bhamjee, a doctor, had no basis upon which to demand that Medscheme (an authorized medical scheme) pay him directly.
In this conclusion, the Court seemed to recognise that although section 59(2) makes a basis upon which medical schemes may expel obligations owed to customers by reimbursing service providers directly, the section doesn't oblige a medical scheme to take action when the provider had lodged an account with the medical scheme.
This viewpoint was affirmed in the fairly recently resolved and reportable matter of Tshwane Pharmacy (Pty) Ltd v GEMS that was heard by the North Gauteng High Court under case number 28532/11.
In this situation the Applicant (a service provider) applied to Court on an emergency basis for an order pointing that the Respondent (a registered medical scheme) generate payment directly to them, and not to their associates.
The Applicant fought that the key phrase in section 59(2) of the Act is "benefit due to the customer or provider of the service" which with a common sense understanding of the area it means that when a member has not paid the service provider of the service the medical scheme has no discernment but is required to repay the supplier.
A Legal Court failed to accept this discussion, and held that section 59(2) must be interpreted in context. Subsection (1) provides that the provider of a service who has rendered a service is obligated to furnish the member interested in an account comprising prescribed information. Subsection (2) then provides that when such an account has been rendered the medical scheme may pay to the member or the provider of the service the bonus owing to that member or supplier of the service.
The Court also held that, in the context of the section, the benefit yet to be paid must make reference to the amount owing by the member to the supplier for the services supplied. The Court mentioned that it's inconsequential that the benefit becomes due to the customer by virtue of the agreement concerning the customer and the medical scheme and, to the provider, thanks to the contract involving the member and the provider. The subsection does not build an obligation on the medical scheme to pay the supplier.
Moreover, the Court held that the subsection clearly provides that payments is subjected to the guidelines of the medical scheme, and in the case of the Respondent it's regulations stated unambiguously how the Respondent has the right to pay either the customer and the supplier of the service.
Consequently, the Court identified no basis for a duty on the Respondent to pay the Applicant directly and laid off the application along with costs.
From the above it's very clear that to assure repayment for services rendered by service providers ought to either claim payment from their patients, or make sure that they've contractual agreements with the medical schemes. Right now, our Courts seem unwilling to demand a legal responsibility on medical schemes for making payments directly to companies even without this kind of contractual arrangement.
About the Author:
Learn about medical law and the medical schemes act from the best in the industry. Dirk Markhen is a specialist in construction law and also practices the law of medicine.
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