After the Fund's decision to pay medical benefits has been cancelled, against which body may it claim the amount corresponding to those benefits, and on what showing?
General information · Not legal advice
Material to check
In a practice file we read the Fund's original payment decision, the later decision cancelling it, and the treatment records showing what care was given. We also read the Fund's claim papers to the health insurance body and any answer to them.
These are types of material to look for, not evidence already verified by PRO SE.
Where readings differ
One reading takes every condition in sequence: the Fund has paid medical benefits to a beneficiary, that payment decision has been cancelled, and the benefits paid are recognised as equivalent to health insurance medical benefits payable under the National Health Insurance Act or the Medical Aid Act; only then may the Fund claim from the National Health Insurance Health Insurance Corporation or the relevant mayor, county head or district office the amount corresponding to those benefits.
Another reading marks what the provision fixes and what it does not: the claim runs from the Fund to that health insurance body rather than from the beneficiary, and the amount is the amount corresponding to those equivalent benefits, so only how the claim is made and pursued remains outside what this provision states.
Your judgment
If the cancellation decision does not identify which treatments the cancelled payment covered, how could the file establish that they were equivalent to health insurance medical benefits?
PRO SE does not make this decision or keep a case record on this public site.When to reconsider
We look at this again if the provision is amended to change which bodies may be claimed from, when equivalence is required, or how the claim is made, or if a court decision defines what counts as benefits equivalent to health insurance medical benefits.