Victory for consumers against Profmed and Council for Medical Schemes

What do you do when a statutory regulatory body disastrously misapplies the law? And what do you do when consumers are diddled out of benefits they should get by tricky wording in a medical aid’s benefits schedule? You lodge a complaint. You appeal. You persevere. You keep following up. And eventually you succeed in obtaining justice for consumers.

We’re delighted to announce that we have successfully concluded a claim on behalf of a counselling psychologist and her client against Profmed. Not only have they agreed to pay out the full claim, they have also amended the benefits from 2022 to cover future claims.

The client suffers from a psychiatric condition which requires long-term therapy. His psychologist has specialist experience in treating the condition and the client and therapist have built up a relationship of trust- the client tells us that he has benefitted enormously from being under the care of his psychologist and would struggle to face life without the regular sessions.

The client is a member of Profmed medical aid. Profmed provides cover for 15 sessions with a psychologist per year, but they specify that the psychologist must be registered as a clinical psychologist. They initially paid for the first client’s sessions in 2019, but then refused to pay further and even demanded repayment of the sessions they had paid for. The reason they gave, was that the psychologist was not registered as a clinical psychologist. The psychologist is registered as a counselling psychologist.

A bit of background on the different registration categories of psychologists. Psychologists register as either clinical, counselling, industrial, educational or research psychologists upon graduation. The training for the different registration categories is very similar, and the choice of category is usually determined by the preference of the university at which one studied. We only have around 17 000 registered psychologists in South Africa, but we have around 2.5 million South Africans who need psychological care each year. As you can tell, psychologists, especially in rural areas, or those working for the State have to serve clients with all kinds of psychological problems otherwise even more desperate South Africans will be left without care.

However, during 2008 and 2011 the Health Professions Council issued Scopes of Practice regulations which reserved certain work for certain registration categories. Clinical psychologists, who make up about one third of SA psychologists, were allocated the most prevalent conditions, such as depression and the other categories of psychologists were excluded from treating those. The Scopes of Practice regulations were set aside by the Cape High Court in 2017 after a court application was launched. The Minister of Health decided to not replace the Scopes. When legislation is repealed by court, it no longer exists and does not form part of our law.

Our firm assisted the psychologist and the client with lodging a complaint against Profmed with the Council for Medical Schemes in June 2020. The CMS issued a ruling on 20 November 2020 in which they decided that Profmed was entitled to limit its benefits to clinical psychologists and, astoundingly, in support for their view, they quote the (repealed) Scopes of Practice regulations. We were rendered speechless for a while, and then lodged an appeal with the CMS Appeal Board. We were assured by the Council that the appeal would be decided around July 2021- already a long wait. The Council further covered themselves in glory by failing to schedule the appeal hearing. After we had emailed them for the 9th time asking for a progress report, the appeal was set down for 30th November 2021.

At that stage, Profmed approached us to offer full payment of the client’s claims (i.e. 15 sessions per year to date) and announced that they have changed their benefit schedule as from 1 January 2022 to cover therapy by counselling psychologists up to 15 sessions per year, provided that the client was referred to the psychologist by a psychiatrist initially. This amounts to a triumph for the psychologist and her client, who will be fully reimbursed and future claims will also be covered.

What is regrettable, is that Profmed is again excluding cover for its members for all psychological treatment provided by clinical and educational psychologists. It’s strange that Profmed, whose members are professionals like psychologists, find it ethically acceptable to exclude their members from cover for psychological treatment based on an arbitrary exclusion of all of the registration categories of psychology save one. That in a country where, according to Department of Health research, 25% of us require psychological intervention every year.

And what boggles the mind is that the Council for Medical Schemes can make such a terrible error in adjudicating on a complaint- their adjudicators failed to notice that one of the few pieces of legislation which they need to be able to apply and interpret was repealed by a court four years previously.

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