It does happen that from time to time, one would need medical attention by consulting doctors, hospitalization, and/or purchasing medication. Generally, if you do not use the public health care strictly subsidized and paid for by the South African government, you would use your medical aid to pay for those services.

Medical Aid only covers certain items and for a certain amount, if there is a shortfall, who is liable? What can the medical service provider do to recover the shortfall, and how does that affect the consumer?

This article will explore answers to this question and caution on the adverse consequences of debt collection.

THE PROCUREMENT OF MEDICAL SERVICES IS GOVERNED BY THE LAW OF CONTRACT

When a consumer engages the services of a doctor, is admitted to a medical facility or purchases medication, the transaction is governed by a contract between the consumer (patient) and the medical service provider (doctor, hospital, or pharmacy and the like). The consumer has the responsibility to pay for services or medication they receive, and the service provider has to render services as required. In general practice, the consumer would conclude another contract with a third party (medical aid insurer) to the extent that such third party is liable for payment to the medical service providers as and when such services are engaged in in terms of the medical aid policy terms and conditions.

Notwithstanding the fact that a consumer engaged a medical aid, they remain legally liable as the consumer to the contractual agreement between themselves and the medical service provider. This comes to light when, for some reason, the medical aid does not pay for certain medical services or medication, the consumer remains liable even if they thought or assumed that the medical aid would pay or should pay.

LIABILITY LOOPHOLE AND TRAP

In practice, it happens quite often that a consumer would go to a doctor or purchase medication, the doctor or pharmacy would not expect a cash payment on the understanding and tender of the consumer that their medical aid would pay in due course, but they would render services. When it later happens or appears that the medical aid did not pay the doctor or pharmacy, the latter has an option to recover what is due from the consumer directly. This commences the process of debt collection.

The doctor or pharmacy would then engage debt collectors or attorneys to recover the outstanding and due balance for their services rendered or goods (medication) provided. It happens more often than not in practice that the consumer would not be aware that their medical aid would not have paid for their medical services and that they are consequently liable until it is late.

When the outstanding balance is due, the medical services provider would sue the consumer, claiming the capital debt (services rendered and goods provided, as the case may be) as well as interest and the collection fees. Consequently, this results in consumers owing substantial amounts that only began as a fraction.

CONCLUSION

It is advisable that as a consumer, you remember that even if you have medical aid, you remain liable for services and goods you purchase, whether the medical aid pays or not and for whatever reason. Secondly, ensure each time, by checking with your medical aid and doctor or pharmacy, that your accounts are duly and timeously paid. Don't be passive; this may cost you a lot.

When a medical service provider contacts you claiming payment for their services or goods provided, it may be advisable that you engage the opinion of a knowledgeable attorney to advise you on possible options available to you in the said legal process. Such may include prescription of debt, holding your medical aid liable, or querying the account rendered and claimed for by the said medical services provider or practitioner.