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Pretoria, South Africa — Once again, Discovery Health has failed to secure a court order compelling the Road Accident Fund (RAF) to pay past claims for medical expenses where these expenses were paid by medical schemes.
Heard on Tuesday, the case – declaring the RAF to be in breach of a previous high court order related to its liability for the payment of past disputed medical expenses – has been dismissed with costs by the High Court in Pretoria.
The court found that; “the rules published by the Discovery Medical scheme are only for its members and the scheme and not third parties like the RAF. The rule dealing with recovering from the RAF what the scheme has paid in discharge of its contractual and statutory obligations is a rule of Discovery Medical Scheme’s own making. It cannot bind third parties, including the RAF.”
The ruling was handed down by the court, comprising Judge Dunstan Mlambo, Judge President of the Gauteng Division of the High Court, Judge Noluntu Bam and Judge Ingrid Opperman.
The dispute was first reported in August 2022 when the RAF decided it would reject claims for medical expenses where these expenses were paid by medical schemes. The RAF is liable for compensating all road accident victims in South Africa for medical expenses they incur if found not to be solely responsible for causing the accidents. Claimants found to have been driving drunk or not wearing seatbelt, the RAF will penalise them by excluding or limiting their claim.
Historically, a person’s medical insurer membership doesn’t remove RAF’s responsibilities. Naturally, schemes cover the initial medical expenses arising from motor vehicle accidents incurred by its members. Once RAF settles an accident victim’s claim which can take years, the scheme will be reimbursed by RAF for past medical expenses covered — regardless of whether their medical aid has already paid for those expenses.
In October 2022, the Discovery Health Medical Scheme took the RAF to the High Court in Pretoria, in terms of section 18(3) of the Superior Courts Act, to compel the RAF to resume processing medical scheme members’ legitimate claims.
In March 2024, it succeeded in interdicting the fund from implementing its directive to reject claims if a medical scheme has already paid them. Discovery submitted it has lost over R130 million since the decision in August, and it will lose R500m a year for not claiming from RAF.
The company further argued the decision would result in members not being able to access other medical treatment because their cover limit and medical savings would have been exhausted. This also meant you will have to pay more for the same medical cover.
Maintaining that RAF is not an insurer, the High Court also referred to the Government Employees Medical Scheme (GEMS), the third-largest medical scheme in the country, which it said, “does not oblige members in its rules to claim any past medical expenses from the Fund”.
Responding to the findings, RAF CEO Collins Letsoalo said: “We are Delighted to be finally vindicated by this judgment. The RAF management received a lot of criticism from many interested parties on this matter. We were correct to stay the course and refuse to be intimidated. This outcome is now case law which will be studied by law students and quoted in court cases well into the future.”
Disagreeing with the ruling. Discovery Health intends to apply for leave to appeal, per latest media reports — as it believes the matter warrants the attention of the Supreme Court of Appeal.
