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Prescription for victory: Board of Healthcare Funders to appeal against judgment in favour of Council for Medical Schemes

Prescription for victory: Board of Healthcare Funders to appeal against judgment in favour of Council for Medical Schemes
Lisakanya Venna
By Lisakanya Venna
3 Apr 2025
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The protracted legal dispute between the Board of Healthcare Funders and the Council for Medical Schemes over low-cost benefit options has entered another chapter following recent developments in the Gauteng Division of the High Court.

The Gauteng Division of the High Court this week dismissed the Board of Healthcare Funders’ application to compel the Council for Medical Schemes to permit medical schemes to offer low-cost benefit options. 

The ruling, delivered on Tuesday, 1 April 2025, marks a critical moment in South Africa’s healthcare debate, with significant implications for low-income earners who rely on private healthcare services paid out of pocket. While the Council for Medical Schemes welcomed the judgment as a validation of its regulatory framework, the Board of Healthcare Funders has vowed to appeal, prolonging the contentious battle over affordable private healthcare access.

Read more: Battle continues for medical schemes to offer low-cost benefit options

Court ruling


While ruling on the matter, judge AJ Ledwaba pointed out that the Board of Healthcare Funders had “provided no actual proof or evidence that any of its medical schemes it claims to represent submitted to the Council for Medical Schemes an exemption application which was rejected on any basis contrary to the act.’’

The court also addressed the Board of Healthcare Funders’ concerns regarding health insurance exemptions granted by the Council for Medical Schemes. Judge Ledwaba affirmed that these exemptions were issued in compliance with the Medical Schemes Act and were supported by relevant authorities, including the National Treasury and the national Department of Health.

The court further noted that the Board of Healthcare Funders failed to provide evidence that any medical scheme applications for low-cost benefit options exemptions had been rejected due to this moratorium. In rejecting the board’s call for relief, Judge Ledwaba concluded that “the application fails both on points (at the outset) and the merits”, ordering the board to cover legal costs.

Board vows to fight on


The board has announced its intention to appeal. The organisation emphasised that low-cost benefit options represented a practical solution to expand private healthcare access for 10 million South Africans who could not afford full medical scheme cover, but relied on out of pocket payments for private healthcare services.

Council for Medical Schemes extends olive branch


The council welcomed the judgment, although Dr Musa Gumede, its registrar, stated that: “The council does not necessarily claim or see this as a victorious moment. We have extended a hand to the Board of Healthcare Funders on several occasions to resolve their displeasures with our policy and regulatory decisions as highlighted by the court.”

According to Stephen Monamodi, senior manager of communications at the Council for Medical Schemes, this engagement will be crucial for addressing concerns and finding common ground. 

“The door is always open from our side,” he said. As part of this effort, the Council for Medical Schemes would continue to monitor health insurance products that had been granted exemptions, ensuring they provided reliable benefits, were affordable, and offered quality services.

The release of the low-cost benefit options report in February 2025 by the national Department of Health, outlining the Council for Medical Schemes’ stance on low-cost benefit options, presents a dual-pronged proposal. This includes either a phased elimination of exempted insurance products alongside Low-Cost Benefit Options rejection, or the regulated introduction of low-cost benefit options. The report’s release may prompt a review of existing regulations, aligning them with national health objectives and ensuring compliance with the Medical Schemes Act.

Catch up



  • What this means for you:The Health Funders Association previously told Daily Maverick that: “A key purpose of the Medical Schemes Act is to provide financial protection for members. This is why we believe that low-cost benefit options should reside within the social solidarity framework of the act.”

    In practical terms, this means that South Africans who do not belong to medical schemes and rely on out-of-pocket payments for private healthcare services may soon have a more affordable option. The low-cost benefit options could address this gap by offering affordable primary healthcare packages to individuals who are currently excluded from medical scheme coverage, potentially expanding access to private healthcare services across the country. 



Battle history


The Council for Medical Schemes first adopted a resolution in August 2015 to establish a framework for low-cost benefit options offered by medical schemes. However, implementation stalled due to concerns from the national Department of Health, which argued that low-cost benefit options were not comprehensive and failed to address national health priorities such as HIV and other diseases.

By 2022, the council was still drafting guidelines for low-cost benefit options, prompting the Board of Healthcare Funders to take legal action, accusing the council of delaying implementation in favor of National Health Insurance (NHI). In November 2023, the council finalised low-cost benefit options guidelines and submitted them to the Department of Health for approval. DM

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