Pretoria - Medical aid schemes say they too will be out of pocket if a new directive by the Road Accident Fund (RAF) to reject claims for past medical expenses if the claimant’s medical aid had already been paid is not immediately stopped.
Discovery Health has launched an urgent application against the RAF and Transport Minister Fikile Mbalula, in which it will ask the Gauteng High Court, Pretoria, to declare the directive issued on August 12, 2022, unlawful.
Discovery Health said not only did the RAF Act not allow the entity to refuse paying for the medical expenses, which a road accident victim had already incurred, but such a decision would have dire financial consequences for each medical aid scheme in the country.
Discovery said in court papers that it estimated that this loss to medical schemes could be in the region of R500 million a year.
Professor Roseanne Harris, head of policy and regulatory affairs at Discovery, said approximately 15% of South Africans had private medical insurance. The RAF’s 2019/20 annual report records that it paid R3.3 billion to claimants in respect of claims relating to medical expenses.
Using these figures, a conservative estimate indicates that the annual value of claims for past medical expenses where the medical scheme has already paid would be around R500m a year.
Harris explained that medical schemes paid their members’ medical expenses in accordance with the benefits due to them under their policy and then assisted their members claim these expenses – and any other heads of damages – from the RAF.
According to her, the immediate change brought by the latest notice from the RAF without prior warning meant that medical schemes must carry the full cost of these expenses incurred after a vehicle accident.
“This will put a huge strain on medical schemes in circumstances where they have had no opportunity to prepare for the change,” she said.
It will be argued during the urgent application next week that the RAF Act makes no provision for limiting liability in cases where a private medical scheme has already paid for a claimant’s past medical expenses.
Discovery pointed out that another court, during a judgment delivered in 2010, made it clear that the RAF was liable for the past medical costs incurred by a claimant even though they had claimed the money from their insurer.
“Close to nine million people in South Africa are members of medical schemes.
“All of these people are at risk of being deprived of their entitlement to compensation for past medical expenses in the event that they are a victim in a road accident.”
Harris added that this also meant that medical schemes were no longer receiving reimbursement for past medical expenses received by their members from the RAF.
“Discovery Health anticipates that a significant number of claims will be settled and finalised on the basis of unlawful settlement offers flowing from the new directive.”
The RAF is still expected to file their answers to these applications.
Pretoria News