Insurer fails to get Road Accident Fund to pay medical fees

A bid by Discovery Health to compel the Road Accident Fund to process the medical bills of its clients at this stage has failed. Picture: File

A bid by Discovery Health to compel the Road Accident Fund to process the medical bills of its clients at this stage has failed. Picture: File

Published Sep 26, 2023


Pretoria - A desperate bid by Discovery Health to compel the Road Accident Fund (RAF) to process the medical bills of its clients at this stage – until the Constitutional Court has spoken the last word – has failed.

While the RAF is heading to the Concourt, Discovery Health is embroiled in legal proceedings to try and ensure the victory it scored earlier in the Gauteng High Court remains on the cards – at least for now.

A judge earlier put an end to a directive the RAF had issued in August, saying it would no longer pay for past hospital and medical claims issued by members of medical aid schemes.

The initial order by Judge Mandla Mbongwe followed an urgent application by Discovery Health after the RAF directive was issued, stating that with immediate effect, it would make no payments to claimants if their medical aid scheme had already paid for their medical expenses arising from a vehicle accident.

Discovery argued that medical aid schemes would be out of pocket if the new directive to reject claims for past medical expenses already paid was implemented.

In January, the court dismissed an application by the RAF for leave to appeal against the judgment, declaring the directive pertaining to medical aid payments unlawful.

The RAF then approached the Supreme Court of Appeal for leave to appeal, but this was turned down by the SCA.

The fund decided to approach the Apex Court.

The problem facing Discovery Health was that, pending the outcome of the ongoing legal battle, the original order granted in its favour was suspended in law.

Discovery once again turned to the court for an order that the fund had to resume payments in the interim. But it lost this application.

Discovery now launched an urgent application for leave to appeal against the judgment dismissing its application for uplifting the suspension.

The medical aid argued that medical aids are losing millions daily as it cannot at this stage claim from the fund the medical costs incurred by members involved in vehicle accidents.

Discovery further argued that the order is definitive of the medical scheme’s right to claim reimbursements for past medical expenses for the entire period that Judge Mbongwe’s judgment is suspended pending the fund’s appeal to the Concourt.

In turning down its urgent application on Friday, Judge Nomsa Khumalo said Discovery had failed to demonstrate sufficient degree of exceptionality to justify the order for leave for the upliftment of the suspension.

“Having further carefully considered the matter, I could not find any circumstances that are persuasive that the order is appealable or that it is in the interest of justice that the order be rendered appealable and leave to appeal be granted,” she said.

The RAF’s CEO, Collins Letsoalo, said it has always been the position of the fund the decision is not appealable, and Discovery Health has no interest or right to claim from the fund.

He referred to Judge Khumalo’s remark that neither Discovery nor the medical schemes it represents have a right to directly claim from the fund.

“It is apparent that Discovery Health and its clients have ‘no faith’ in medical scheme members and would rather strong arm them into an underhanded scheme of arrangements to claim from a social benefit scheme in order to pay over the social benefit to Discovery Health and its clients,” Letsoalo said.

He further referred to Judge Khumalo’s remarks, where she said in her judgment: “Discovery would rather bypass the member claimants in whom it has alleged to have no faith to do the right thing, and legally have no right to prevent from conducting their cases in whatever manner they so wish, including negotiating settlements, to secure direct payment from the fund.”

Letsoalo said the fund was further vindicated by the confirmation of its assertion that the payment for prescribed minimum benefit and emergency medical condition is not conditional upon the fund reimbursing those expenses.

“It is obligatory for the medical schemes to pay those in full without any co-payments or deductibles,” Letsoalo said.

“The contributions of the medical schemes could never have been determined with this false premise that medical schemes have a right to coerce members to claim from social security funds.”

Pretoria News