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Thread: neglegence in sending medical bill to medical aid on time, what do we do?

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    neglegence in sending medical bill to medical aid on time, what do we do?

    In August 2010 My wife to be at that stage, receive medical treatment at certain south african hospital. the treatment she received in Hospital was contracted to an outside company. Since all these treatments received was received in hospital we assumend all hospitilisation was covered by the bill send by the hospital. On the 9th of April 2013, my wife received an sms from a medical bills and collections company that she needed to call them regarding an outstanding account.

    During the period from August 2010 to 9 April 2013 she did not receive any form of communication from the service provider that the account was still outstanding. She never received any invoice or telephone call although her contact details stayed unchanged. When she returned the call she was informed that the treatment she received in August 2010 was not paid and that she need to arrange for payments. We were shocked and she replied that she was never contacted once in nearly three years. The company claimed that they did phone and posted invoices which we never received. On 10 April 2013, my wife phoned the medical aid to enquiry why the claim was never paid. The medical aid confirmed that claim was only received September 2012 (two years after service was received). The medical aid rejected the claim. The medical aid also confirmed that if they received the claim on time they would have probably paid.

    Now I want to enquire what I need to do and what steps I need to follow. May I refuse to pay the outstanding account? Or am I still liable for account although the service provider obviously was negligent in sending the claim to the medical aid on time?


    The following is an frequently asked question on the website of the counsel of medical schemes

    CLAIMS, PAYMENT OF ACCOUNTS AND MEDICAL SAVINGS ACCOUNT (MSA)

    Q43. Within what period of time must my account for services or claim reach my medical scheme?

    The account must be submitted not later than the last day of the fourth month following the month in which the service was rendered.

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    Site Caretaker Dave A's Avatar
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    Quote Originally Posted by polar101 View Post
    On 10 April 2013, my wife phoned the medical aid to enquiry why the claim was never paid. The medical aid confirmed that claim was only received September 2012 (two years after service was received). The medical aid rejected the claim. The medical aid also confirmed that if they received the claim on time they would have probably paid.
    My suggestion is get that in writing.

    From there -
    When the medical institution sues you, you can countersue for damages in the same amount due to them failing to submit their claim timeously.
    It should then become a fight between the medical institution and the medical aid as to whether the medical aid's rule is legal. (I'd be surprised if there isn't a legal precedent on that particular point already).
    The trouble with opportunity is it normally comes dressed up as work.

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    Platinum Member sterne.law@gmail.com's Avatar
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    Quote Originally Posted by Dave A View Post
    My suggestion is get that in writing.

    From there -
    When the medical institution sues you, you can countersue for damages in the same amount due to them failing to submit their claim timeously.
    It should then become a fight between the medical institution and the medical aid as to whether the medical aid's rule is legal. (I'd be surprised if there isn't a legal precedent on that particular point already).
    Time bar clauses were explored in Barkhuizen v Napier, 2007 (5) SA 323 (CC)
    I would think that the 4 months is not unreasonable for submitting an account, nor against public policy.
    The issue would be the failure of the med aid to submit were they negligient etc, etc
    It all starts pointing to an expensive scrap unfortunately, the nature of legal proceedings.
    You cant refuse to pay, service provider has no contartc with med aid - not my problem.
    you coudl wait for summons and join the med aid as a third party or go on offensive and sue teh med aid straight, essentially for payment of the bill plus costs.
    Anthony Sterne

    www.acumenholdings.co.za
    DISCLAIMER The above is merely a comment in discussion form and an open public arena. It does not constitute a legal opinion or professional advice in any manner or form.

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    Platinum Member sterne.law@gmail.com's Avatar
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    or keep low and in AUGUST 2013 claim prescription as a defence
    Anthony Sterne

    www.acumenholdings.co.za
    DISCLAIMER The above is merely a comment in discussion form and an open public arena. It does not constitute a legal opinion or professional advice in any manner or form.

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