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South Africa decisions
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Marais v Road Accident Fund (2540/2021) [2025] ZAWCHC 324 (30 July 2025)
The High Court held the RAF liable for disputed accident-related medical expenses and ordered an unrestricted section 17(4)(a) undertaking for future care.
Basson v Road Accident Fund (5213/2021) [2025] ZAWCHC 229 (30 May 2025)
The court found that the plaintiff is entitled to recover past hospital and medical expenses from the Road Accident Fund, including those paid by her medical aid scheme, Discovery Health. The defendant's reliance on the Medical Schemes Act and section 19(d)(i) of the RAF Act was rejected, as the contractual arrangement between the plaintiff and Discovery Health to reimburse the scheme upon recovery from the RAF is valid and enforceable. The court emphasized that the RAF Act is compensatory in nature and aims to restore the plaintiff to her pre-accident financial position. The provisions of th…
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Esack N.O v Road Accident Fund [2025] ZAWCHC 27; 2025 (4) SA 201 (WCC) (4 February 2025)
The court held that the defendant is liable to compensate the plaintiff for past hospital and medical expenses paid by the deceased's medical aid scheme. The majority judgment in Discovery Health did not alter the established legal position, as it did not decide the deductibility of medical aid payments and cannot override Supreme Court of Appeal authority. The principle of res inter alios acta remains applicable, and payments by medical aid schemes, even for prescribed minimum benefits or emergency medical conditions, are not deductible from the plaintiff's claim against the Road Accident Fu…
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KeyHealth Medical Scheme v Ngoepe N.O and Others (A203/2021) [2022] ZAGPPHC 758 (10 October 2022)
The court held that KeyHealth Medical Scheme is prohibited by Regulation 10(6) of the Medical Schemes Act from using a member's Medical Savings Account to fund prescribed minimum benefits. Regulation 8 further obliges the scheme to pay PMBs in full from its risk pool, without co-payment or deductibles. KeyHealth's own Rule 17.5 reinforces this prohibition by stating that no limitations or exclusions apply to PMBs. The court found that KeyHealth's argument, based on the absence of an express prohibition, was flawed; the correct approach is to determine whether there is authorisation for such c…
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M.D and Another v Medihelp Medical Scheme and Another (2022-010668) [2022] ZAGPPHC 640 (26 August 2022)
The High Court granted urgent interim relief ordering Medihelp to fund Elaprase for a child with MPS II pending a CMS complaint.
Council for Medical Schemes v Genesis Medical Scheme (20518/2014) [2015] ZASCA 161; 2016 (1) SA 429 (SCA); [2016] 1 All SA 15 (SCA) (16 November 2015)
The Supreme Court of Appeal held that Genesis Medical Scheme cannot, by its rules, avoid its statutory obligation to pay the full costs of treatment for prescribed minimum benefit conditions, even where such treatment is administered in a private institution. The Medical Schemes Act and its regulations require medical schemes to pay in full for PMB treatment, and scheme rules cannot override these statutory obligations. Genesis's failure to appoint designated service providers means it cannot rely on the regulatory provisions limiting liability to DSPs. The court found that public policy and…
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Genesis Medical Scheme v Minister of Health; In re: Medi-Clinic Southern Africa (Pty) Ltd and Others v Treatment Action Campaign NPC and Others (15268/14) [2015] ZAWCHC 124; [2015] 4 All SA 302 (WCC) (29 July 2015)
High Court decision granting leave to intervene and admit amici in a review of Medical Schemes Regulation 8.
Board of Health Care Funders of the Southern Africa (Association Incorporated Under Section 21 of the Companies Act, 61 of 1973) and Another v Council for Medical Schemes and Others (70018/10) [2011] ZAGPPHC 206 (7 November 2011)
The court found that the first applicant did not have locus standi to seek declaratory relief regarding the interpretation of regulation 8(1) of the General Regulations under the Medical Schemes Act. The first applicant failed to demonstrate a direct and substantial legal interest in the subject matter, as the judgment would not prejudicially affect it but rather the medical schemes themselves. Only a limited number of medical schemes supported the application, and not all affected schemes were joined as parties. The court held that a declaratory order cannot be granted where it would affect…
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Voortrekker Apteek BK v Fedhealth Medical Scheme and Others (485/2010) [2010] ZAFSHC 58 (17 June 2010)
The court held that the scheme operated by the first and second respondents, which designates Medi-Rite as the preferred pharmacy and imposes a 40% co-payment for members who obtain chronic medication from other pharmacies, is expressly authorised by Regulation 8 of the Medical Schemes Act. The scheme does not constitute a bonus, discount, or incentive scheme as prohibited by section 18A of the Medicines Act, since the price of medicine is regulated and uniform across pharmacies. Any conflict between the Medical Schemes Act and the Medicines Act is resolved in favour of the Medical Schemes Ac…
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