Pretoria - The Road Accident Fund (RAF) will oppose the urgent application to reject claims for past medical expenses if the claimant’s medical aid had already footed the member’s expenses following a vehicle accident.
The Gauteng High Court, Pretoria is due to hear the urgent application by Discovery Health against the new RAF directive tomorrow.
Discovery Health will ask that the directive issued on August 12 2022 be declared unlawful.
In papers filed in opposition of the application, RAF acting CEO Phathutshedzo Lukhwareni said they were only liable to pay a claimant for the full amount of past medical expenses where the accident victim had to pay these expenses.
The RAF said it had no obligation to refund a claimant for these expenses if the person’s medical aid had already paid the expenses.
Medical aid schemes say they too will be out of pocket if a new directive is not stopped immediately.
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.
But Lukhwareni denied that medical aid schemes would incur losses.
“This is because when a medical aid pays an account submitted to them by a health-care provider, they do so in discharging their obligation to pay the benefits to which their members are entitled in terms of their contractual relationship.”
Discovery said in court papers that it estimated that the loss to medical schemes could be in the region of R500 million a year if the RAF persisted with its stance.
It said 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.
Lukhwareni said medical aids operated in terms of the Medical Schemes Act and had contracts with its members. It had nothing to do with the RAF and thus they were not entitled to question the directive issued by the entity.
“When the benefit to which a member is entitled has been paid by their medical aid to the health-care service provider, the member does not expect the medical aid scheme to ask for that benefit to be repaid to it.
“In fact, a plaintiff whose past medical costs have been paid by a medical scheme should not even claim for those (from the RAF) because they have not in fact or in law actually suffered that loss.
“It is also not a loss to a medical scheme because the scheme pays a benefit which it is in law obliged to do,” Lukhwareni said.
Pretoria News