AD CAMERA WEI nova 8i CMS Council for Medical Schemes 4 April 2022 RULINGS ISSUED BY THE OFFICE OF THE REGISTRAR The CMS hereby publishes summaries of rulings recently issued by the Complaints Adjudication Unit in respect of complaints lodged against regulated entities, in terms of Section 47 of the Medical Schemes Act. These rulings are published solely for information purposes and may not be taken to be precedent setting in any way. Decisions articulated in these rulings may still be appealed in terms of Section 48 of the Medical Schemes Act. The CMS reserves the right to modify or remove any information published herein, without prior notice. The contents of these rulings do not constitute legal or medical advice and may not be taken out of context. The findings and any opinions expressed in these rulings are based on the specific facts of each complaint, the evidence submitted, and applicable legal provisions. The CMS does not assume liability or accept responsibility for any claims for damages or any errors, omissions, arising out of use, misunderstanding or misinterpretation, or with regard to the accuracy or sufficiency of the information contained in these publications. Identifiable personal information of the complainants and any associated individuals have been redacted for their protection. All rights reserved.F v Genesis Medical Scheme Regulation 15H(c) The complaint concerned the funding of treatment a member underwent due to complications after a PMB procedure. The member had developed an Acute Respiratory Distress Syndrome (ARDS). He therefore underwent an Extracorporeal Membrane Oxygenation (ECMO) to support the lungs, however the Scheme short-paid accounts in respect of the EMCO. In its response, the Scheme submitted that the claims were short funded as the ECMO is not considered to be PMB level of care for the member's diagnosis. The matter was subsequently referred to the CMS Clinical Review Committee (CRC) for clinical opinion on whether the procedure constituted PMB level of care or not. Having reviewed the clinical reports, the CRC advised that although an ECMO is not the first line of therapy for Acute Respiratory Distress Syndrome (ARDS), in this specific case, the clinical motivation provided by the treating doctor justified a deviation from the clinical protocol. The provisions of Regulation 15H (c) were found to be applicable in this case as they state that medical schemes must make provision "for appropriate exceptions where a protocol has been ineffective or causes or would have caused harm to a beneficiary without penalty to that beneficiary" HUAWEI nova 8i The CRC found that the member in this particular case, qualified for funding in terms of Regulation I QUAD CAMERA 15H(c). The Scheme was therefore directed to fund the Complainant's account in full, as the treatment provided to the member constituted a PMB entitlement.Question]. (15 maIkS) 1.1 1.2 1.3 1.4 1.5 Identify the roleplayer(s) who dealt with the complaint. (1) Identify the type of medical scheme that is referred to in the case and motivate your answer. (2) Explain the importance of the ruling in terms of fairness towards members and the medical scheme. (5) In the case, reference is made to the Council for Medical Schemes Clinical Review Committee. Briefly explain why the complaint had to be reviewed by this committee. (3) Identify the relevant roleplayers who oversee that Genesis has proper control measures in place to mitigate the risk of the medical scheme receiving such a complaint in the future. (4)