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Medical Schemes Act, 1998 (Act No. 131 of 1998)

Chapter 1 : Definitions

1. Definitions

 

(1) In this Act, unless inconsistent with the context—

 

"Academy"

[Definition deleted by section 53 of the General Intelligence Laws Amendment Act, 2013 (Act No. 11 of 2013)]

 

"actuary"

means any fellow of an institute, faculty, society or chapter of actuaries approved by the Minister of Finance;

 

"administrator"

means any person who has been accredited by the Council in terms of section 58, and shall, where any obligation has been placed on a medical scheme in terms of this Act, also mean a medical scheme;

 

"Agency"

[Definition deleted by section 53 of the General Intelligence Laws Amendment Act, 2013 (Act No. 11 of 2013)]

 

"Appeal Board"

means the Appeal Board established by section 50(1);

 

"beneficiary "

means a member or a person admitted as a dependant of a member;

 

"board of trustees"

means the board of trustees charged with the managing of the affairs of a medical scheme, and which has been elected or appointed under its rules;

 

"Broker"

means a person whose business or part thereof entails providing broker services but does not include —

(i) an employer or employer representative who provides service or advice exclusively to the employees of that employer;
(ii) a trade union or trade union representative who provides service or advice exclusively to members of that trade union;
(iii) a person who provides service or advice exclusively for the purposes of performing his or her normal functions as a trustee, principal officer employee or administrator of a medical scheme,

unless a person referred to in subparagraph (i). (ii) or (iii) elects to be accredited as a broker, or actively markets or canvasses for membership of a medical scheme

 

"broker services"

means —

(a) the provision of service or advice in respect of the introduction or
(b) the ongoing provision of service or advice in respect of access to, or admission of members to a medical scheme or benefits or services offered by, a medical scheme;

 

"business of a medical scheme"

means the business of undertaking, in return for a premium or contribution, the liability associated with one or more of the following activities:

(a) Providing for the obtaining of any relevant health service;
(b) granting assistance in defraying expenditure incurred in connection with the rendering of any relevant health service; or
(c) rendering a relevant health service, either by the medical scheme itself, or by any supplier or group of suppliers of a relevant health service or by any person, in association with or in terms of an agreement with a medical scheme;

[Definition amended by section 257 of Act No. 45 of 2013]

 

"Council"

means the Council for Medical Schemes established by section 3;

 

"complaint"

means a complaint against any person required to be registered or accredited in terms of this Act, or any person whose professional activities are regulated by this Act, and alleging that such person has —

(a) acted, or failed to act, in contravention of this Act; or
(b) acted improperly in relation to any matter which falls within the jurisdiction of the Council;

 

"condition-specific waiting period"
means a. period during which a beneficiary is not entitled to claim benefits in respect of a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for membership was made;
 
"curator"
means a curator appointed under section 56;
 
"dependant"

means—

(a) the spouse or partner, dependent children or other members of the member's immediate family in respect of whom the member is liable for family care and support; or
(b) any other person who, under the rules of a medical scheme, is recognised as a dependant of a member

 

"financial year"

means each period of 12 months ending on 31 December;

 

"general waiting period"

means a period in which a beneficiary is not entitled to claim any benefits;

 

"Master"

means the Master of the High Court;

 

"medical scheme"

means any medical scheme registered under section 24(1);

 

"member"

means a person who has been enrolled or admitted as a member of a medical scheme, or who, in terms of the rules of a medical scheme, is a member of such medical scheme;

 

"Minister"

means the Minister of Health;

 

"officer"

means any member of a board of trustees, any manager, principal officer, treasurer, clerk or other employee of the medical scheme, but does not include the auditor of the medical scheme;

 

"prescribed"

means prescribed by regulation;

 

"principal officer"

means the principal officer appointed in terms of section 57(4)(a);

 

"Registrar"

means the Registrar of Medical Schemes appointed in terms of section 18;

 

"reinsurance contract"

means any contractual arrangement whereby some element of risk contained in the rules of the medical scheme is transferred to a reinsurer in return for some consideration;

 

"reinsurer"

means an insurer —

(a) registered as a long-term insurer in terms of section 9 of the Long-term Insurance Act, 1998 (Act No. 52 of 1998), unless that insurer is prohibited from engaging in the practice of reinsurance in terms of section 10 of that Act; or
(b) registered as a short-term insurer in terms of section 9 of the Short-term Insurance Act, 1998 (Act No. 53 of 1998), unless that insurer is prohibited from engaging in the practice of reinsurance in terms of section 10 of that Act;

 

relevant health service

means any health care treatment of any person by a person registered in terms of any law, which treatment has as its object—

(a) the physical or mental examination of that person;
(b) the diagnosis, treatment or prevention of any physical or mental defect, illness or deficiency;
(c) the giving of advice in relation to any such defect, illness or deficiency;
(d) the giving of advice in relation to, or treatment of, any condition arising out of a pregnancy, including the termination thereof;
(e) the prescribing or supplying of any medicine, appliance or apparatus in relation to any such defect, illness or deficiency or a pregnancy, including the termination thereof; or
(f) nursing or midwifery,

and includes an ambulance service, and the supply of accommodation in an institution established or registered in terms of any law as a hospital, maternity home, nursing home or similar institution where nursing is practiced, or any other institution where surgical or other medical activities are performed, and such accommodation is necessitated by any physical or mental defect, illness or deficiency or by a pregnancy;

 

"restricted membership scheme"

means a medical scheme, the rules of which restrict the eligibility for membership by reference to—

(a) employment or former employment or both employment or former employment in a profession, trade, industry or calling;
(b) employment or former employment or both employment or former employment by a particular employer, or by an employer included in a particular class of employers;
(c) membership or former membership or both membership or former membership of a particular profession, professional association or union; or
(d) any other prescribed matter;

 

"rules"

means the rules of a medical scheme and include—

(a) the provisions of the law, charter, deed of settlement, memorandum of association or other document by which the medical scheme is constituted;
(b) the articles of association or other rules for the conduct of the business of the medical scheme; and
(c) the provisions relating to the benefits which may be granted by and the contributions which may become payable to the medical scheme;

 

"Service"

[Definition deleted by section 53 of the General Intelligence Laws Amendment Act, 2013 (Act No. 11 of 2013)]

 

"this Act"

includes the regulations.

 

(2) For the purposes of this Act, any reference in this Act to a medical scheme shall be construed as a reference to that medical scheme or to the board of trustees of that medical scheme, as the case may be.