The Decryption Of “pay In Full” In Terms Of The Healthcare Schemes Act

In 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 Court by way of a application to release a declaratory order with regards to the explanation of the words “pay in full” in regulation 8(1) of the General Regulations made pursuant towards the Professional medical Schemes Act, 131 of 1998.

The applicants contended that the Courts needed to decide three problems, namely: 1. The first applicant’s right to institute actions for declaratory relief; 2. The interest and locus standi of the intervening members in opposing the relief searched for by way of the appliers; and 3. The concise explanation of the words “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 power since 1 January 2000. In accordance with the applicants, the actual problem started on 11 November 2008 once the Appeal Board resolved two cases on appeal which were referred by the Appeal Committee with respect to section 50 of the Act. The Appeal Committee as well as the Appeal Board had, pursuant to those two judgements, interpreted the phrase “pay in full” in regulation 8 to indicate that the medical scheme should make full payment of a service providers’ invoice in respect of the fees of supplying health care services for Prescribed Minimum Benefits if you don’t take the policies of the health care scheme into account in working with any grievances.

It was the applicants’ contention that “pay in full” signifies settlement according to the rules of the Healthcare Scheme, while according to the participants, the decisions by the Appeal Board haven’t been questioned up to now and presently healthcare aid schemes are bound to this power while having to pay for service providers’ invoices in full.

The primary problem by the respondents could be that the first applicant had no immediate and substantial interest in the application since the judgment would not have a direct impact on it. Even though the first candidate contended it represented 75 licensed healthcare aid schemes and for that reason had locus standi, the Court identified this not to be. It was because of the reason that the first applicant saw suitable to have the second candidate, who’s an authorized healthcare aid scheme, amalgamated. In addition, only 15 registered professional medical schemes, within the founding and supplementary founding affidavits, affirmed that the declaratory order should be sought.

A Legal Court held that had the 1st candidate been so certain that it defended all 75 medical aid schemes it would not have been essential to join the 2nd applicant or to obtain affidavits and signatures of 15 members of the first applicant. A Legal Court determined out of this that the first applicant didn’t in fact legally represent 75 members, but only the 15 members stated in the papers.

The non-joinder of all of the professional medical schemes rendered the application fatally defective as the Court could not discover that the first candidate, as a standard representative of the medical schemes, will be prejudicially impacted by a verdict, but found that its members may be prejudicially affected and accordingly, all the participants ought to have jointly instituted the request for any declaratory order.

The Judge learned that the 1st applicant did not have locus standi for these reasons:

1. The matter was one which could be classified as a representative issue, but not all the medical schemes have been amalgamated and it has not been launched as a representative matter due to the fact that the first applicant did not have any mandate to litigate on behalf of all 75 of its associates;

2. In order to commence steps in terms of Section 38 of the Constitution, a litigant must reveal that the right enshrined in the Bill of Rights may be encroached upon along with sufficient interest in the relief desired. The 1st candidate didn’t clearly aver such encroachment and the Court found that the primary Complainant wouldn’t be directly influenced by the ruling and was lacking a satisfactory interest in the relief sought.

With regard to the second applicant the court held that it could not succeed in the application by itself, as not one of the other healthcare aid schemes or managers had been joined.

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