Stay in your lane, Road Accident Fund tells Council for Medical Schemes

• Clash over fund’s decision to stop paying for medical aid members’ care arising from road accidents

The Road Accident Fund (RAF) has told the Council for Medical Schemes (CMS) to “stay in its lane” after two CMS staff members wrote an article suggesting the RAF should continue reimbursing medical aids for the cost of members’ treatment after vehicle accidents.

The RAF, which notches up tens of billions in losses every year, decided last August to stop paying for medical aid members’ care relating to road accidents.

This decision came even as medical aid members pay towards the RAF through mandatory levies included in petrol and diesel prices.

The article by the medical aid regulator said the refusal by the RAF to refund medical schemes was “not in line with the Medical Schemes Act”. The RAF called on the CMS to withdraw its article, saying “the level of misinformation in this article cannot be left unchallenged”.

The refusal to pay is the subject of a court case between Discovery Health, which is an administrator of 19 medical schemes, and the RAF.

The high court and the Supreme Court of Appeal sided with Discovery and found the RAF’s decision not to reimburse scheme members for accident treatment to be unlawful. But the RAF has approached the Constitutional Court and is not reimbursing medical schemes while it waits to see if the apex court will hear its appeal.

Previously, the RAF would reimburse medical aids that had already paid for their beneficiaries’ hospital treatment. Discovery Health says the RAF’s nonpayment for vehicle accident treatment is costing SA’s medical aids R2m a day collectively.

A draft amendment bill that aims to reduce the RAF’s losses entails not paying for medical aid members’ treatment and setting the prices for what it will pay towards medical procedures. This is in contrast to medical aids, which have to cover the cost of emergency treatment and certain procedures, called prescribed minimum benefits.

Two weeks ago, the CMS, which regulates medical schemes, had an article on the financial industry website FA News explaining that when the RAF does not pay for care relating to road accidents, it disadvantages all medical aid members. This is because medical aid money is shared in a fund between all members.

When the RAF does not pay up, there is less money available for all beneficiaries.

The RAF said medical schemes have no right to be reimbursed from a “social benefit fund”. It criticised the regulator as taking Discovery Health’s side, calling it a “sudden alliance, unholy it seems”. “The CMS should stay in its lane and stick to its mandate, as per the Medical Schemes Act.”

The CMS asked for more time before commenting. SA has about 800,000 road accidents a year, according to figures from the department of transport.