Medical Schemes Act, 1998 (Act No. 131 of 1998)Chapter 5 : Rules of Medical Scheme29. Matters for which rules shall provide |
| (1) | The Registrar shall not register a medical scheme under section 24, and no medical scheme shall carry on any business, unless provision is made in its rules for the following matters: |
| (a) | The appointment or election of a board of trustees consisting of persons who are fit and proper to manage the business contemplated by the medical scheme. |
| (b) | The appointment of a principal officer by the board of trustees who is a fit and proper person to hold such office. |
| (c) | The appointment, removal from office, powers and remuneration of officers of a medical scheme. |
| (d) | The manner in which contracts and other documents binding the medical scheme shall be executed. |
| (e) | The custody of the securities, books, documents and other effects of the medical scheme. |
| (f) | The appointment of the auditor of a medical scheme and the duration of such appointment |
| (g) | The power to invest funds. |
| (h) | Subject to the provisions of this Act, the manner in which and the circumstances under which a medical scheme shall be terminated or dissolved. |
| (i) | The appointment of a liquidator in the case of a voluntary dissolution. |
| (j) | The settlement of any complaint or dispute. |
| (k) | The amendment of the rules in accordance with the provisions of section 31. |
| (l) | The giving of advance written notice to members of any change in contributions, membership fees or subscriptions and benefits or any other condition affecting their membership. |
| (m) | The manner of calling the annual general meeting and special general meetings of members, the quorum necessary for the transaction of business at such meetings and the manner of voting thereat. |
| (n) | The terms and conditions applicable to the admission of a person as a member and his or her dependants, which terms and conditions shall provide for the determination of contributions on the basis of income or the number of dependants or both the income and the number of dependants, and shall not provide for any other grounds, including age, sex, past or present state of health, of the applicant or one or more of the applicant's dependants, the frequency of rendering of relevant health services to an applicant or one or more of the applicant's dependants other than for the provisions as prescribed. |
| (o) | The scope and level of minimum benefits that are to be available to beneficiaries as may be prescribed. |
| (p) | No limitation shall apply to the reimbursement of any relevant health service obtained by a member from a public hospital where this service complies with the general scope and level as contemplated in paragraph (o) and may not be different from the entitlement in terms of a service available to a public hospital patient. |
| (q) | The payment of any benefits according to— |
| (i) | a scale, tariff or recommended guide; or |
| (ii) | specific directives prescribed in the rules of the medical scheme. |
| (r) | The dependants of a member are entitled to participate in the same benefit option as the member. |
| (s) | The continuation, subject to such conditions as may be prescribed, of the membership of a member, who retires from the service of his or her employer or whose employment is terminated by his or her employer on account of age, ill-health or other disability and his or her dependants. |
| (t) | For continued membership of a member’s dependants, subject to conditions as may be prescribed, after the death of that member, until such dependant becomes a member of, or is admitted as a dependant of a member of another medical scheme. |
| (u) | If the members of a medical scheme who are members of that medical scheme by virtue of their employment by a particular employer terminate their membership of the said medical scheme with the object of obtaining membership of another medical scheme or of establishing a new medical scheme, such other or new medical scheme shall admit to membership, without a waiting period or the imposition of new restrictions on account of the state of his or her health or the health of any of his or her dependants, any member or a dependant of such first mentioned medical scheme who— |
| (i) | is a person or persons contemplated in paragraph (s); or |
| (ii) | is a person or persons contemplated in paragraph (t). |
| (2) | A medical scheme shall not cancel or suspend a member's membership or that of any of his or her dependants, except on the grounds of— |
| (a) | failure to pay, within the time allowed in the medical scheme's rules, the membership fees required in such rules; |
| (b) | failure to repay any debt due to the medical scheme; |
| (c) | submission of fraudulent claims; |
| (d) | committing any fraudulent act; or |
| (e) | the non-disclosure of material information. |
| (3) | A medical scheme shall not Provide in its rules— |
| (a) | for the exclusion of any applicant or a dependant of an applicant, subject to the conditions as may be prescribed, from membership except for a restricted membership scheme as provided for in this Act; |
| (b) | for the exclusion of any applicant or a dependant of an applicant who would otherwise be eligible for membership to a restricted membership scheme; and |
| (c) | for the imposition of waiting periods other than as provided for in section 29(A). |