Medical schemes short-changing members – CMS

Legalbrief Today Issue 4807

Medical schemes continue to fail to pay or short-pay members' claims for prescribed minimum benefits (PMBs), sparking complaints to the medical schemes regulator, notes a Sunday Times report. The Council for Medical Schemes (CMS) says in its latest annual report that 1 242 of 3 808 complaints lodged last year related to PMBs – benefits that schemes are legally obliged to cover. It also notes that some schemes are still using members' medical savings accounts, rather than scheme funds, to pay for the treatment of PMBs. This is a contravention of the law, yet when picked out about it by the regulator the schemes concerned offered no explanation but merely advised that the relevant accounts had been reversed and reprocessed to pay from the scheme's risk benefit. The annual report states that this conduct shows more work needs to be done by the council to ensure full compliance by medical schemes and their administrators with the application of the law, ‘and that there must be consequences for those entities who contravene the (Medical Schemes) Act’. One of the regulations under the Act states that schemes must pay PMB claims in full regardless of what the doctor or other healthcare provider charges. But last year there were 285 complaints about schemes that paid PMB claims at lower scheme rates. The annual report does not record how many of these complaints were resolved in members' favour.

Full Sunday Times report (subscription needed)