THE MEDICAL SCHEMES COUNCIL APPEAL COMMITTEE (DOC) by suchenfz

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									THE MEDICAL SCHEMES COUNCIL APPEAL COMMITTEE




In the matter between:



KK                                                       Appellant



and



DISCOVERY HEALTH MEDICAL SCHEME                            Respondent




APPEAL RULING




1.     Mr KK appeals against a decision of Discovery Health Medical

       Scheme, in terms of which the scheme declined to meet the costs of

       orthodontic treatment, the removal of wisdom teeth and maxillo-facial

       surgery for the appellant between February 2003 and August 2004.



2.     The appellant joined Discovery Health at the beginning of February

       2003. He claims that during 2003 he was covered for hospitalisation

       for the removal of wisdom teeth and for maxillo-facial surgery, but that

       in 2004 he was informed that he was not covered for such

       hospitalisation.   He claims that cover for such procedures was

       reinstated in respect of the year 2005.
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3.   The appellant was admitted to Discovery Health Medical Scheme

     upon his acceptance of a counter-offer from the scheme signed by him

     on 27 January 2003. That counter-offer contained an exclusion for 12

     months in respect of maxillo-facial procedures for pre-existing

     conditions, orthodontics, and extractions and exposures.



4.   Those exclusions operated so as to disentitle the appellant from

     claiming for the procedures that he underwent between February 2003

     and February 2004.



5.   In any event, even had his membership not been subject to these

     exclusions, Discovery Health Medical Scheme would not have been

     obliged to compensate the appellant.



6.   Upon joining Discovery Health the appellant had elected to join the

     coastal core plan. Provision is made in this plan for a medical savings

     account and the member is required to choose whether or not he or

     she wishes to have such an account. The appellant chose not to have

     a medical savings account.



7.   In terms of the respondent’s coastal core benefit option rules for 2004,

     payment for orthodontic treatment was not covered, and was to be

     funded from the medical savings account if such account existed. The

     same applied to maxillo-facial treatment performed out of hospital.
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8.    As far as in-hospital maxillo-facial treatment was provided, the same

      benefits applied, save that certain specified procedures would have

      been paid for by Discovery Health. The treatment which the appellant

      underwent did not fall within the specified procedures.



9.    There is no evidence that these conditions changed year to year from

      2003 to 2005.


10.   The effect of the aforegoing is that Discovery Health was not obliged

      to pay for the procedures to which the appellant was subjected. Had

      the appellant elected to create a medical savings account, and had

      sufficient funds available in such account, the costs of such

      procedures could have been met from these funds. However, in the

      absence of such an account, given the conditions applicable to

      Discovery Health’s coastal core plan, the appellant was not covered

      for the procedures in respect of which he now seeks payment.



11.   In the premises, the appeal is dismissed.


DATED AT SANDTON THIS             DAY OF APRIL 2005



P R JAMMY
MEMBER: APPEAL COMMITTEE

								
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