M.D and Another v Medihelp Medical Scheme and Another (2022-010668) [2022] ZAGPPHC 640 (26 August 2022)

M.D and Another v Medihelp Medical Scheme and Another (2022-010668) [2022] ZAGPPHC 640 (26 August 2022)

The court found that MPS II is a prescribed minimum benefit condition under category 901K of Annexure A to the Medical Schemes Act. The evidence established that Elaprase is the only available and effective treatment for MPS II and is prescribed in both private and public sector hospitals, despite the rarity of the condition. The court held that the regulatory requirement to follow prevailing public hospital practice must be interpreted in the context of rare diseases, where patient numbers are low and local protocols may not exist. Affidavits from public hospital doctors confirmed that Elaprase is used in public facilities, and European guidelines are followed as de facto protocols. The...

Citation
[2022] ZAGPPHC 640
Parties
Applicant: M.D; Applicant: Rare Diseases of South Africa NPC; Respondent: Medihelp Medical Scheme; Respondent: The Council for Medical Schemes
Court
North Gauteng High Court, Pretoria
Jurisdiction
South Africa
Judgment Date
26 August 2022
Case Number
2022-010668
Procedural Posture
Urgent Application / Interim Relief (part A) Pending Complaint Determination (part B)
Outcome
Interim relief granted; the medical scheme is ordered to authorize and pay for Elaprase treatment for the applicant's child pending the outcome of the complaint to the Council for Medical Schemes.
Judges
Millar
Legal Topics
Prescribed Minimum Benefits, Medical Schemes Act, Interim Relief, Child Best Interests, Rare Disease Treatment
Administrative Law Civil Procedure Family and Children Prescribed Minimum Benefits Medical Schemes Act Interim Relief Child Best Interests Rare Disease Treatment

Case Brief

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Parties

M.D

Applicant

Rare Diseases of South Africa NPC

Applicant

Medihelp Medical Scheme

Respondent

The Council for Medical Schemes

Respondent

Procedural Posture

Urgent Application / Interim Relief (part A) Pending Complaint Determination (part B)

Legal Issues

  1. 1 Whether Hunters Syndrome MPS II qualifies as a Prescribed Minimum Benefit (PMB) condition under the Medical Schemes Act.
  2. 2 Whether the applicant is entitled to interim relief compelling the medical scheme to pay for Elaprase treatment pending the outcome of a complaint to the Council for Medical Schemes.
  3. 3 Whether Elaprase is the prevailing and predominant public hospital practice for treating MPS II.

Ratio Decidendi

The court found that MPS II is a prescribed minimum benefit condition under category 901K of Annexure A to the Medical Schemes Act. The evidence established that Elaprase is the only available and effective treatment for MPS II and is prescribed in both private and public sector hospitals, despite the rarity of the condition. The court held that the regulatory requirement to follow prevailing public hospital practice must be interpreted in the context of rare diseases, where patient numbers are low and local protocols may not exist. Affidavits from public hospital doctors confirmed that Elaprase is used in public facilities, and European guidelines are followed as de facto protocols. The...

Court Disposition

Interim relief granted; the medical scheme is ordered to authorize and pay for Elaprase treatment for the applicant's child pending the outcome of the complaint to the Council for Medical Schemes.

Orders

  • Hunters Syndrome MPS II is declared a Prescribed Minimum Benefit (PMB) Condition under category 901K as listed in Annexure A of the Regulations of the Medical Schemes Act, 131 of 1998.
  • Pending the resolution of Part B, the First Respondent is ordered to authorize the treatment and care costs of all medical interventions required by Z[....] and prescribed by his treating practitioners for Hunters Syndrome MPS II as PMB level of care, including Elaprase, within 30 days of this order.