16. BENEFITS
16.1 Members are entitled to benefits during a financial year, as set out in Annexures B and C, and such benefits extend through the Member to his registered Dependants. A Member must, on admission, elect to participate in any of the available options, detailed in Annexure B;
16.2 A Member is entitled to change from one benefit option to another subject to the following conditions:
16.2.1 application to
change from one benefit option to another benefit option may only be
made with effect from 1 January of any financial year and must be in
writing and lodged with the Principal Officer by not later than 30
November prior to the year from which it is intended that the change
will take place, provided that the Member has had at least thirty
(30) days prior notification of any intended changes. This date may
be amended at the discretion of the Board;
16.2.2 any application that falls outside of the
Scheme’s rules will be referred to the Board for its decision;
16.3 The Scheme shall, where an account has been rendered, pay any benefit due to a Member, either to that Member or to the supplier of the relevant health service who rendered the account, within thirty (30) days of receipt of the claim pertaining to such benefit;
16.4 If a Member or his Dependant (referred to in this rule as “the Patient”) intends to receive or has received treatment or hospitalisation for an illness or injury, the Board shall have the right to require the Patient, at the Scheme’s Cost, to submit to an examination by any medical practitioner the Board may nominate and must communicate this to the attending practitioner. The Board, at its discretion and subject to the Prescribed Minimum Benefits, may disallow any further benefits for that particular illness or injury if:
16.4.1 the attending
practitioner or the practitioner nominated by the Board advises that
treatment or hospitalisation is not justified; or
16.4.2 the Patient acts contrary to, or fails to
act upon, the advice given to him by the attending practitioner or
by the practitioner nominated by the Board.
16.5 Should the results of the medical examination referred to in rule 16.4 differ from the attending practitioner, the matter will be referred to medical arbitration;
16.6 Any benefit option offered in Annexure B covers in full the Cost of the Prescribed Minimum Benefits rendered by a State Hospital, or any service provider who charges the rates paid by the Scheme in terms of the option the Member has chosen, or any other service provider designated by the Scheme from time to time in terms of Regulation 8 of the Act; and
16.7 The Scheme may exclude services from benefits as set out in Annexure C.
17. RE-AUTHORISATION AND CASE MANAGEMENT
17.1 Pre-authorisation: in all cases where prior approval and authorisation by the Scheme (“Preauthorisation”) is required in respect of any benefit, even though such Pre-authorisation may be given by the Scheme, the payment of any claim relating thereto will always be subject to sufficient benefits being available to the Member at the time of payment, and further that his membership has not been terminated or suspended for any reason. Benefits that are subject to Pre-authorisation are subject further to the Scheme protocols and are set out in the annexures to this document; and
17.2 Case Management is the process carried out by trained healthcare professionals who ensure that Beneficiaries receive the optimum treatment for all hospital or related incidents at an appropriate facility and level of care, at the same time following the Scheme’s protocols and applying Cost containment measures.
18. DISEASE MANAGEMENT PROGRAMMES
18.1 The Board has the right to introduce disease management programmes and treatment protocols from time to time. In terms of such programmes, certain medical conditions, inclusive of benefits in Annexure B, are subject to such management by the Scheme’s Designated Service Provider Network; and
18.2 If a Member fails to register with such a programme or does not comply with the conditions and protocols of the programme, no benefit shall be payable other than those laid down in the Prescribed Minimum Benefits and the corresponding treatment algorithms, where appropriate.
19.1 Payment of accounts is restricted to the maximum amount of the benefit entitlement in terms of the applicable benefit and option elected;
19.2 The Scheme may, whether by agreement or not with any supplier or group of suppliers of a service, pay the benefit to which the Member is entitled, directly to the supplier who rendered the service;
19.3 Where the Scheme has paid an account or portion of an account or any benefit to which a Member is not entitled, whether payment is made to the Member or the supplier of service, the amount of any such overpayment is recoverable by the Scheme;
19.4 Notwithstanding the provisions of this rule, the Scheme has the right to pay any benefit directly to the Member concerned; and
19.5 Subject to the provisions of the Act and subject to any other law or regulation in force, the Scheme shall be entitled to offset against any amounts owed to that Member or his Dependant, any sum of money owed by that Member or Dependant to the Scheme and the Member and Dependant consents to this.
20. GOVERNANCE
20.1 The affairs of the Scheme shall be managed according to these rules by a Board consisting of ten (10) persons who are fit and proper to be trustees and who will serve terms of office of three (3) years each;
20.2 Five (5) of such trustees must be elected by Members from amongst Members; and
20.3 Five (5) of such trustees, with relevant experience, must be appointed by the Board of the Scheme;
20.4 The following persons are not eligible to serve as members of the Board:
20.4.1 a person under the
age of twenty-one (21) years;
20.4.2 an employee, director, officer, consultant
or contractor of the Administrator of the Scheme or the holding
company subsidiary, joint venture or associate of that
Administrator;
20.4.3 a person, including a legal person,
associated with the Administrator of the Scheme or of any
controlling or subsidiary company of the Administrator;
20.4.4 the Principal Officer of the Scheme;
20.4.5 the Auditor of the Scheme;
20.4.6 a board member of PPS Limited;
20.4.7 a broker.
20.5 Retiring members of the Board are eligible for re-election or re-appointment;
20.6 Nominations to fill vacancies in respect of elected trustees, signed by the candidate signifying his consent to stand for election, together with an accompanying Curriculum Vitae, must be submitted to the Scheme by not later than 30 April of the year concerned and the election must be carried out by the Members by means of a ballot vote to be received by the Scheme fourteen (14) days prior to the annual general meeting of the Scheme;
20.7 Should a casual vacancy of a trustee occur during a term of office, such vacancy will be filled as follows:
20.7.1 the vacancy of a
trustee appointed in terms of rule 20.2 will be filled by
appointment by the Board from Members. A person so appointed must
retire at the first ensuing annual general meeting; or
20.7.2 the vacancy of a trustee appointed in terms
of rule 20.3 will be filled by appointment by the Board. A person so
appointed shall serve the remaining period of the term of office of
the trustee in whose place he is appointed;
20.8 The Board may co-opt a knowledgeable person to assist in its deliberations, provided that such person shall not have a vote;
20.9 Half of the members of the Board plus one (1) is a quorum at meetings of the Board;
20.10 The Board must elect from its number the Chairman and Vice-Chairman at the first meeting of the Board of Trustees following an annual general meeting, and will serve a term of office of one (1) year each;
20.11 The Chairman and Vice-Chairman may be voted out of office before the end of their term of office by a two-thirds majority show of hands;
20.12 The retiring Chairman and Vice-Chairman are eligible for re-election;
20.13 In the absence of the Chairman and Vice-Chairman, the Board members present must elect one of their number to preside;
20.14 The Chairman must preside over meetings of the Board and ensure due and proper conduct at meetings;
20.15 Matters serving before the Board must be decided by a majority vote and in the event of an equality of votes, the Chairman has a casting vote in addition to his deliberative vote;
20.16 A member of the Board may resign at any time by giving written notice to the Board;
20.17 A member of the Board ceases to hold office if:-
20.17.1 he becomes
mentally ill or incapable of managing his affairs;
20.17.2 he is declared insolvent or has surrendered
his estate for the benefit of his creditor;
20.17.3 he is convicted, whether in the Republic or
elsewhere, of theft, fraud, forgery or uttering of a forged document
of perjury;
20.17.4 he is removed by the Court from any office
of trust on account of misconduct;
20.17.5 he is disqualified under any law from
carrying on his profession;
20.17.6 being a Board member elected by Members of
the Scheme, he ceases to be a Member of the Scheme;
20.17.7 he absents himself from three (3)
consecutive meetings of the Board without the permission of the
Chairman; or
20.17.8 he is removed from office by the Council
for Medical Schemes in terms of Section 46 of the Act;
20.18 The provisions of rules 20.17.1 to 20.17.5 apply mutatis mutandis to the Principal Officer;
20.19 The Board must meet at least once every three (3) months or at such intervals as it may deem necessary;
20.20 The Chairman may convene a special meeting should the necessity arise. Any three (3) members of the Board may request the Chairman to convene a special meeting of the Board, stating the matters to be discussed at such meeting;
20.21 Members of the Board may be reimbursed for all reasonable expenses incurred by them in the performance of their duties as trustees;
20.22 Members of the Board may be remunerated as determined from time to time at the annual general meeting.
