Docstoc

THE COUNCIL FOR MEDICAL SCHEMES APPEAL COMMITTEE

Document Sample
THE COUNCIL FOR MEDICAL SCHEMES APPEAL COMMITTEE Powered By Docstoc
					                THE COUNCIL FOR MEDICAL SCHEMES


                          APPEAL COMMITTEE




In the matter between:



K.F                                                Appellant



and



MUNIMED MEDICAL SCHEME                                     Respondent



______________________________________________________________

                         APPEAL RULING

_____________________________________________________________




1.     When Mr K.F joined Munimed on 1 July 2003 the benefit schedule

       applicable to his membership provided for unlimited orthodontic

       treatment.




2.     However, in January 2004 Munimed restructured its benefits and

       imposed an annual limit of R2 000,00 on specialised dentistry
                                                                             2



     including orthodontics.




3.   Mr K.F had joined Munimed as a municipal employee in terms of an

     arrangement between his employer and the scheme. He was told, at

     his date of joining, that he could not move schemes until 31 December

     2004 unless he changed jobs.




4.   Mr K.F is aggrieved because he is incurring ongoing orthodontic

     expenditure in respect of his sons, and is locked into a scheme which

     has changed its benefits in the time since he elected to join.




5.   To the extent that Mr K.F's complaint is directed against the fact that if

     the scheme has changed its benefits, there is no substance to this

     complaint. The Act allows schemes to change their benefits from time

     to time provided they go through the procedure prescribed in their

     rules, and there is no suggestion that Munimed has not complied with

     such a procedure in this instance.




6.   Mr K.F's complaint is further that he might have chosen to join another

     scheme had he known that these benefits might be altered.


7.   The blame for that circumstance cannot be laid at the door of
                                                                             3



     Munimed since it was Mr K.F's employers that created the condition

     that he belong to the scheme until the end of 2004. Mr K.F's complaint

     in this regard should be directed at his employer, not at the scheme.




8.   The appeal committee takes note of the scheme's submission that Mr

     K.F is entitled to change benefit options within the Munimed scheme,

     and may select a benefit option that has less restrictive limitations on

     orthodontic treatment. That, of course, is Mr K.F's decision.




9.   In the circumstances the appeal committee believes that Mr K.F's

     complaint is without substance and his appeal is accordingly

     dismissed.




DATED AT PRETORIA THIS              DAY OF FEBRUARY 2005

				
DOCUMENT INFO
Shared By:
Stats:
views:8
posted:12/5/2009
language:English
pages:3
Description: THE COUNCIL FOR MEDICAL SCHEMES APPEAL COMMITTEE