THE MEDICAL SCHEMES COUNCIL APPEAL COMMITTEE THE MEDICAL SCHEMES by monkey6

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									THE MEDICAL SCHEMES COUNCIL APPEAL COMMITTEE




In the matter between:



SSAppellant



and



OMNI HEALTH MEDICAL AID SCHEME                            Respondent




APPEAL RULING




1.     In response to a request for authorisation, the respondent, Omni

       Health Medical Scheme, wrote to Mr SS, the appellant, on 27 October

       2003 and indicated that the scheme would pay for a knee brace

       required for his wife, such payment to be made from the appellant’s

       appliance benefit of R6 000,00 for the year of 2003.



2.     The invoice in respect of the aforementioned knee brace was

       delivered to Medscheme, the administrators for the respondent, on 19

       December 2003.



3.     However, due to administrative difficulties on the respondent’s part, or
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     on the part of its administrator, Medscheme, this account was not

     settled during the 2003 calendar year.



4.   In 2004 the appellant applied for, and received, authorisation for a

     hearing aid for his wife.



5.   On 19 March 2004, the respondent paid the doctor’s invoice for the

     hearing aid.



6.   Omnihealth paid for the cost of the hearing aid and incorrectly, in the

     view of the Appeal Committee, allocated this cost to the 2003 benefit

     year.   The appeal committee therefore rules that the cost of the

     hearing aid, in accordance with the authorisation granted to the

     appellant, be allocated from the appellant’s appliance limit for the 2004

     calendar year.


7.   The respondent subsequently wrote to the appellant on 30 August

     2004 informing him that the account for the knee brace would not be

     paid since the appellant’s appliance limit for 2003 had been used to

     pay for the hearing aid for his wife.



8.   The appellant’s annual appliance limit could not accommodate

     payment both for a knee brace and for the hearing aid.



9.   The appeal committee is of the view that the refusal by the respondent

     to pay for the knee brace for the appellant’s wife is unjustified.
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      Authorisation for the knee brace was granted in 2003, and the scheme

      was invoiced for the supply of the knee brace in the same year.

      Having undertaken to pay for the knee brace out of the 2003 appliance

      limit the scheme was bound to do so.



10.   The scheme cannot rely on its own administrative inefficiency and

      consequent failure to pay for the knee brace timeously before the

      conclusion of the 2003 calendar year as a reason to deprive the

      appellant of payment to which he was, in accordance with the rules of

      the scheme, entitled. The appeal committee therefore rules that the

      cost of the knee brace must be met, in accordance with the

      authorisation granted to the appellant, from the appellant’s appliance

      limit for the 2003 calendar year.


DATED AT SANDTON THIS                DAY OF MAY 2005



P R JAMMY
APPEAL COMMITTEE MEMBER

								
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