Medical Services Medical Aid Societies Regulations 2000(Statutory Instrument 330 of 2000)

Statutory Instrument 330 of 2000.

Medical Services Medical Aid Societies Regulations 2000

SIs 330/2000, 35/2004

ARRANGEMENT OF SECTIONS

PART I

PRELIMINARY Section

PART II

REGISTRATION OF MEDICAL AID SOCIETIES

3. Register of medical aid societies.
4. Registration of medical aid societies.
5. Restriction on use of names denoting medical aid societies.
6. Business plan of applicant medical aid society. Application for renewal of registration.

PART III

CONDUCT OF MEDICAL AID SOCIETIES

7. Officers of medical aid societies.
8. Disqualification for appointment or election as officer of medical aid society.
9. Discrimination, and exclusion of membership in certain circumstances, prohibited.
10. Matters for which constitution of medical aid society shall provide.
11. Minimum benefits to be made available to members.
12. Minimum membership of medical aid societies.
13. Maximum waiting and settlement periods and permissible deductions from benefits.
14. Extent of restriction of member’s choice of health services.
15. Complaints to societies by members and health-care providers.
16. Termination, suspension and continuation of membership and benefits.

PART IIIA

UNFAIR PRACTICES BY HEALTH-CARE PROVIDERS ANDSOCIETIES

16A. Unfair practices by health-care providers in relation to members.

16B. Unfair practices by societies in relation to health-care providers.

16C. Rectification of unfair practices.

16D. Additional orders in cases of default.

16E. Other offences in connection with unfair practices.

PART IV

FINANCIAL MATTERS

17. Solvency and liquidity ratios of medical aid societies.
18. Encumbrance and investment of funds of medical aid societies.
19. Appointment, duties and powers of auditors of medical aid societies.
20. Audit committee.
21. Accounts, financial statements and returns.

PART V

AMALGAMATION, TRANSFER, DISSOLUTION AND DEREGISTRATION OFMEDICALAID SOCIETIES

22. Amalgamations and transfers of medical aid societies.
23. Voluntary and automatic dissolution of medical aid societies.
24. Compulsory winding up of medical aid societies.
25. Cancellation or variation of registration of societies and measures in lieu of cancellation.
26. Interim management of medical aid society.
27. Transfer of business of medical aid society in lieu of deregistration.

PART VI

ADVISORY COUNCILS

28. Establishment, composition and functions of advisory councils.
29. Meetings of advisory councils.

PART VII

GENERAL

31. Complaints referred to the Secretary.
32. Codes of practice.
33. Existing societies to comply with regulations.
34. Existing low-cost schemes operated by restricted societies.
35. Extension and condonation of non-compliance with time limits.
36. False statements, etc.
37. Multiple claims prohibited.

First Schedule: Application for Registration as a Medical Aid Society.

Second Schedule: Minimum Requirements of Minimum Benefits Scheme for the Purposes of the Proviso to Section

11(4).

Third Schedule: Fees.

Fourth Schedule: Application for renewal of registration as a medical aid society.

IT is hereby notified that the Minister of Health and Child Welfare has, in terms of section 16 of the

Medical Services Act [Chapter 15:13], made the following regulations:—

PART I

PRELIMINARY

1. Title

These regulations may be cited as the Medical Services (Medical Aid Societies) Regulations, 2000.

                                                                                            2.   Interpretation

In these regulations—

“accumulated funds” means the net asset value of a medical aid society, excluding funds set aside for specific purposes and non-distributable reserves;

“appropriate fee” means the appropriate fee prescribed in the Third Schedule in respect of the application for and registration of a society or the renewal of registration of a society;

[Definition inserted by s.i 35 of 2004]

“authorised person” means a person authorised by the Secretary in terms of subsection (1) of section 16C;

[Definition inserted by s.i 35 of 2004]

“board” means the board of trustees or directors charged with overseeing the management of the business of a medical aid society;

“dependant” means—

• the spouse, dependent child, or other member of the member’s immediate family in respect of whom the member is liable for family care and support; or
• any dependent parent or other person who, under the constitution or rules of a medical aid society, is recognised as a dependant of such a member;

“employee group benefits scheme” means a medical scheme benefiting the employees of any employer or combination of employers;

“existing medical aid society” means a society deemed to have been registered in terms of section 17 of the Act;

“fit and proper person” means a person not disqualified to be appointed or elected as a director, trustee, principal officer or independent administrator of a medical aid society in terms of section 8;

“health-care provider” means any of the following persons who or which supplies to a member or dependant of a member a service qualifying for payment or reimbursement by the medical aid society to which the member belongs—

• a medical or dental practitioner, nurse, pharmacist or other health practitioner; or
• a health institution; registered or required to be registered in terms of the Health Professions Act [Chapter 27:19];

“independent administrator” means a person who carries on the business of administering or managing the business of any medical aid society or medical scheme under any agency agreement or similar arrangement with the board of the society and, in a case where the independent administrator is a company, includes every director of the company;

“joint advisory council” means the joint advisory council established in terms of paragraph (b) of subsection (1) of section 28;

“low-cost scheme” means a scheme referred to in subsection (6)of section ll;

“medical aid broker or consultant” means any person providing advice in respect of the admission of members to a medical aid society and related administrative services under an agreement between the broker or consultant and the society, member or employer;

“medical aid card” means a card issued by a society indicating that the person named therein is a member in good standing of the society;

[Definition inserted by s.i 35 of 2004]

“medical aid societies advisory council” means the medical aid societies advisory council established in terms of paragraph (a) of subsection (1) of section 28;

“medical aid society” or “society” means an open m aid society or a restricted medical aid society;

“medical scheme” mean any scheme administered by a medical aid society for the benefit of a specified class of member;

“member” means a person who has been enrolled or admitted as a member of a medical aid society or who, in terms of the constitution or rules of a society, is a member of such society;

“minimum benefits scheme” means the minimum benefits scheme referred to in subsection (4) of section 11;

“officer” means a member of the board of a medical aid society, principal officer, independent administrator, treasurer and any other employee of the society the nature of whose duties may require him to account directly to the board;

“open, medical aid society” means a medical aid society which is not a restricted medical aid society;

“principal officer” means the person directly responsible to the board of a medical aid society for administering or managing the business of the society;

“restricted medical aid society” means a medical aid society the constitution of which restricts the eligibility for membership by reference to—

• employment or former employment in a profession, trade, industry or calling;
• employment or former employment by a particular employer, or by an employer of a particular

class;

and includes a sick fund established or maintained by a municipal or town council in terms of section 147 of the Urban Councils Act [Chapter 29:15];

“specialist medical unit or facility” means— (a)   a medical laboratory; or

• a radiology unit; or
• a medical rehabilitation centre; or
• such other specialist medical unit or facility as the Secretary may, from time to time, notify in writing to medical aid societies after consultation with the medical aid societies advisory council;

“unfair practice” means any practice—

• referred to in paragraph (a), (b) or (c) of section 16A by a health-care provider in relation to a member; or
• referred to in paragraph (a) or (b) of section 16B by a society in relation to a health-care provider;”.

[Definition inserted by s.i 35 of 2004]

“waiting period”, in relation to a member, means the period between the admission of the member into the society and the date on which the member is entitled under the constitution or rules of the society to claim any benefits.

PART II

REGISTRATION OF MEDICAL AID SOCIETIES

                                                                               3.   Register of medical aid societies

(1) he Secretary shall establish and maintain a register of medical aid societies registered in terms of section 4 or deemed to be registered in terms of section 17 of the Act, in which the following shall be recorded—

• the name and address of the medical aid society, and whether it is a restricted or open medical aid society; and
• the date of registration of the medical aid society, if it was registered in terms of section 4; and
• any terms or conditions imposed on the medical aid society upon registration in terms of section 4; and
• the particulars of the cancellation of any registration, and of the restoration of any such cancelled registration; and
• any alterations to the particulars referred to in paragraph (a) or (c).

(2) Any person may inspect the register free of charge at all reasonable times at the premises of the Secretary or at such other place as the Secretary may direct.

                                                                            4.   Registration of medical aid societies

• Any person who wishes to establish or conduct a medical aid society shall apply to the Secretary in the form prescribed in the First Schedule for the registration of The society.
• The application for registration as a medical aid society shall be accompanied by the appropriate fees, two copies of the constitution of the society, a business plan of the society containing the particulars required by section 6 and, if applicable, the rules of the medical aid society and a copy of an agreement or instrument referred to in paragraph (c) of subsection (5) of section 7.
• If the Secretary is satisfied that—
• every person proposed as a member of the board of the medical aid society, and as the principal officer or independent administrator of the society, is a fit and proper person to hold the office concerned; and
• the constitution of the proposed medical aid society complies with section 10; and
• the proposed medical aid society complies with or will be able to comply with these regulations; and (d) the name under which the medical aid society proposes to operate is not a name—
  • which has already been registered; or
  • which so closely resembles the name of a medical aid society already registered that it is likely to be mistaken for it; or
  • which is likely to mislead the public; and

(e) the proposed medical aid society is or will be financially sound; the Secretary shall register the medical aid society and may, in doing so, impose such terms and conditions as he deems necessary.

(4) The Secretary shall, as soon as practicable after registering a medical aid society for the first time, publish a notice in the Gazette setting out—

• the name and address of the medical aid society, and whether it is a restricted or open medical aid society; and
• the date of registration of the medical aid society; and
• any terms or conditions imposed on the medical aid society upon its registration.

[Subsection amended by s.i 35 of 2004]

• The fee for registration shall be refunded to an unsuccessful applicant for registration as a society, but not the application fee. [Subsection inserted by s.i 35 of 2004]
• Every society shall be registered for a period of twelve months ending on the 31st March in the year following that in which it was registered, or, in the case of societies that are first registered after the 31st March, for any part of the period of twelve months ending on the 31st March from the date of the first registration.

[Subsection inserted by s.i 35 of 2004]

                                                            5.   Restriction on use of names denoting medical aid societies

• No person shall, without the consent of the Secretary, conduct any business under a name which includes the words “medical• aid society”, “medical scheme” or any other name which is calculated to indicate or is likely to lead persons to believe that he conducts a medical aid society, unless such business is registered in terms of section 4.
• A person who contravenes subsection (1) shall be guilty of an offence and liable to a fine not exceeding level five or imprisonment for a period not exceeding one year or both.

                                                                     6.   Business plan of applicant medical aid society

The business plan of an applicant medical aid society referred to in subsection (2) of section 4 shall include, or be accompanied by, the following projections based on normal assumptions and the most and least favourable assumptions—

• a projected annual balance sheet for the first two years of operation;
• a projected annual income and expenditure account for the first two years of operation; (c) a projected cash flow statement for the first two years of operation.

                                                                    6A.       Application for renewal of registration

Not later than the 31st March, 2004, and thereafter not later than the end of a period of twelve months ending on the 31st March in each year (or, in the case of societies that are first registered after the 31st March, 2004, not later than the end of any part of the period of twelve months ending on the 31st March from the date of the first registration), a registered society wishing to renew the registration shall make application in the form pre scribed in the Fourth Schedule accompanied by the appropriate fee:

Provided that if there are any material changes to the particulars furnished in connection with the original or previous application for registration, the applicant concerned shall make a new application in terms of section 4.”.

[Section inserted by s.i 35 of 2004]

PART III

CONDUCT OF MEDICAL AU) SOCIETIES

                                                                               7.   Officers of medical aid societies

(1) The board of every medical aid society shall employ or appoint a principal officer or independent administrator of the society:

Provided that—

• where a society employs or appoints both a principal officer and an independent administrator it shall notify the Secretary accordingly and specify which of them is primarily responsible for administering or managing the business of the society;
• in the case of a society established or maintained by a municipal or town council in terms of section 147 of the Urban Councils Act [Chapter 29:151, the council concerned, or any officer or member of the council, may be designated as the principal officer for the purposes of these regulations.
• If the post of the principal officer or independent administrator is vacant for more than thirty days the medical aid society concerned shall immediately notify the Secretary in writing of that fact.
• A principal officer or independent administrator of a medical aid so or medical scheme shall, if appointed or elected as a member of the board of the society, not be present at any meeting of the board while the terms and conditions of his employment or appointment are being decided.
• No member of the board of a society shall participate in the discussion of any matter on the agenda of a meeting of the board in which the board member is interested, unless he has disclosed such interest to the board and the board has agreed that he may participate in the discussion of, and voting on, that matter.
• Whenever a medical aid society appoints or employs a new principal officer it shall transmit to the Secretary, within thirty days of the appointment—
• the reasons, in writing, for the cessation of the employment of the previous principal officer or independent administrator; and
• the particulars of the new principal officer or independent administrator required by Part II of the form prescribed in the First Schedule, as completed by the new principal officer or independent administrator; and
• in the case of the appointment of an independent administrator, a copy of the agreement or instrument appointing the administrator.
• An independent administrator shall keep and account for medical aid society moneys separately from the assets of any other business carried on by the administrator.
• A medical aid society which contravenes subsection (2), (3) or (5) shall be guilty of an offence and liable to a fine not exceeding level five.
• A member of the board of a society who contravenes subsection (4) shall be guilty of an offence and liable to a fine not exceeding level five or imprisonment for a period not exceeding one year or both.
• An independent administrator who contravenes subsection (6) shall be guilty of an offence and liable to a fine not exceeding level five or imprisonment for a period not exceeding one year or both.