Monday, February 10, 2014
The Interpretation of Pay in Full with regards to the Healthcare Schemes Act
During the current matter 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 judge along with a petition to issue a declaratory order regarding the meaning of the phrase "pay in full" in regulation 8(1) of the General Regulations made pursuant for the Professional medical Schemes Act, 131 of 1998.
The applicants put forward the proposition that the Courts had to determine three issues, that is: 1. The first applicants entitlement to initiate proceedings for declaratory aid; 2. The interest and locus standi of the intervening members in opposing the relief sought by the candidates; and 3. The concise explanation of the words "pay in full" in regulation 8(1) of the General Regulations which were promulgated with respect to area 67 of the Act.
Regulation 8 has been around in power since 1 January 2000. According to the candidates, the actual problem commenced on 11 November 2008 when the Appeal Board resolved two cases on appeal which was referred by the Appeal Committee in terms of section 50 of the Act. The Appeal Committee and the Appeal Board had, pursuant to these two judgements, interpreted the phrase "pay in full" in regulation 8 to mean that the professional medical scheme need to effect 100 % payment of a service providers invoice in respect of the charges of providing health care services for Prescribed Minimum Benefits without taking the rules of the health care scheme into consideration in working with any complaints.
It was actually the applicants argument that "pay in full" signifies repayment according to the procedures of the Professional medical Scheme, while according to the respondents, the judgements by the Appeal Board have not been questioned up to now and presently medical aid schemes are bound to this authority and still have to repay service providers accounts entirely.
The main complaint from the participants was that the first applicant didnt have immediate and substantial concern in the application as the judgment will not have an impact over it. Although the first candidate suggested it represented 75 registered medical aid schemes and for that reason had locus standi, the judge found this not to be. This was due to the fact that the first candidate saw suitable to have the second candidate, whos a registered medical aid scheme, combined. In addition, only 15 licensed professional medical schemes, within the starting and extra founding affidavits, verified that a declaratory order needs to be sought.
The Court held that had the first applicant been so sure that it represented all 75 professional medical aid schemes it would not have been essential to join the 2nd applicant or to acquire affidavits and signatures of 15 members of the 1st applicant. The Court deducted from this that the first applicant did not in reality represent 75 members, but only the 15 members pointed out within the documents.
The non-joinder of all the professional medical schemes rendered the application fatally flawed as the Courts couldnt find that the first applicant, as a standard representative of the professional medical schemes, will be prejudicially impacted by a judgment, but learned that its participants may be prejudicially affected and accordingly, many of the participants ought to have jointly implemented the request for a declaratory order.
The Judge found out that the 1st applicant was without locus standi for the reasons:
1. The issue was one that may be considered a representative matter, although not every one of the professional medical schemes have been joined and it has not been started as a representative issue because of the fact that the first applicant didnt have any authority to litigate on behalf of all 75 of its associates;
2. In order to commence steps with respect to Section 38 in the Constitution, a litigant must reveal that the right enshrined in the Bill of Rights has been encroached upon as well as sufficient concern in the relief desired. The initial candidate didnt expressly aver such infringement and the Judge found out that the First Plaintiff would not be directly affected by the verdict and didnt have an adequate concern in the relief sought.
With regard to the second candidate the judge held it will not succeed in the application on its own, as not one of the other healthcare aid schemes or managers have been connected.
The applicants put forward the proposition that the Courts had to determine three issues, that is: 1. The first applicants entitlement to initiate proceedings for declaratory aid; 2. The interest and locus standi of the intervening members in opposing the relief sought by the candidates; and 3. The concise explanation of the words "pay in full" in regulation 8(1) of the General Regulations which were promulgated with respect to area 67 of the Act.
Regulation 8 has been around in power since 1 January 2000. According to the candidates, the actual problem commenced on 11 November 2008 when the Appeal Board resolved two cases on appeal which was referred by the Appeal Committee in terms of section 50 of the Act. The Appeal Committee and the Appeal Board had, pursuant to these two judgements, interpreted the phrase "pay in full" in regulation 8 to mean that the professional medical scheme need to effect 100 % payment of a service providers invoice in respect of the charges of providing health care services for Prescribed Minimum Benefits without taking the rules of the health care scheme into consideration in working with any complaints.
It was actually the applicants argument that "pay in full" signifies repayment according to the procedures of the Professional medical Scheme, while according to the respondents, the judgements by the Appeal Board have not been questioned up to now and presently medical aid schemes are bound to this authority and still have to repay service providers accounts entirely.
The main complaint from the participants was that the first applicant didnt have immediate and substantial concern in the application as the judgment will not have an impact over it. Although the first candidate suggested it represented 75 registered medical aid schemes and for that reason had locus standi, the judge found this not to be. This was due to the fact that the first candidate saw suitable to have the second candidate, whos a registered medical aid scheme, combined. In addition, only 15 licensed professional medical schemes, within the starting and extra founding affidavits, verified that a declaratory order needs to be sought.
The Court held that had the first applicant been so sure that it represented all 75 professional medical aid schemes it would not have been essential to join the 2nd applicant or to acquire affidavits and signatures of 15 members of the 1st applicant. The Court deducted from this that the first applicant did not in reality represent 75 members, but only the 15 members pointed out within the documents.
The non-joinder of all the professional medical schemes rendered the application fatally flawed as the Courts couldnt find that the first applicant, as a standard representative of the professional medical schemes, will be prejudicially impacted by a judgment, but learned that its participants may be prejudicially affected and accordingly, many of the participants ought to have jointly implemented the request for a declaratory order.
The Judge found out that the 1st applicant was without locus standi for the reasons:
1. The issue was one that may be considered a representative matter, although not every one of the professional medical schemes have been joined and it has not been started as a representative issue because of the fact that the first applicant didnt have any authority to litigate on behalf of all 75 of its associates;
2. In order to commence steps with respect to Section 38 in the Constitution, a litigant must reveal that the right enshrined in the Bill of Rights has been encroached upon as well as sufficient concern in the relief desired. The initial candidate didnt expressly aver such infringement and the Judge found out that the First Plaintiff would not be directly affected by the verdict and didnt have an adequate concern in the relief sought.
With regard to the second candidate the judge held it will not succeed in the application on its own, as not one of the other healthcare aid schemes or managers have been connected.
About the Author:
To find out more about contract law and other fields of law, please take a look at Dirk Markhens recommendation for professional construction law attorneys.
Subscribe to:
Post Comments (Atom)
No comments:
Post a Comment