Section 59 hearing mentioned the different medical schemes that are describing doctors based on race and ethnicity. Hence, there is a war raging between medical aids and healthcare practitioners – and patients have progressively become the casualties.

A section 59 investigation into allegations that African and Indian doctors were being treated unfairly by medical schemes. Their claims were being withheld “arbitrarily” in many instances based on their ethnicity and the colour of their skin.

One of the submission after another said how these doctors were being intimidated by schemes through so-called forensic probes and have to sign acknowledgments of debt for huge amounts, were withheld payments of claims or, even blacklisted.

One of the medical practitioner, Dr Aslam Vallee, wept at the hearing as he told about his own “nightmare” encounter with a large medical scheme, back in 2002. Eventually, he was forced to sell his practice and is now suffering from anxiety and depression.

Shafrudeen Amod, a medical law consultant and pharmacist, spoke on the sidelines of the hearing, told City Press about a case which had started in 2007 and was still ongoing. He said it involved a woman who had a brain aneurysm and needed urgent surgery. The patient was prepared for the surgery. Doctors knew that she has to be stabilized before her condition deteriorated. But when the hospital asked for authorization of the surgery, the medical aid declined. The issue had nothing to do with the woman but was between the attending neurosurgeon and the medical aid scheme which had a billing issue with that surgeon. The surgeon was an Indian neurosurgeon and his patient was also Indian.

As it was an emergency, the couple had to pay R25, 000 upfront to stabilize her, and R6 000 for an ambulance to transfer her to a different hospital. So, in total they had to pay about R140 000. The medical aid scheme suspended the woman’s membership a day after she had the operation because she supposedly didn’t disclose she had suffered from headaches in the past.

This is only one of a growing number of cases the National Health Care Professionals’ Association – which has 2 500 members, one of them is Amod who was arranging. More cases were coming steadily and had been submitted to the hearing’s panel confidentially to protect patients’ identities.

At the hearing, Dr Donald Gumede, chairperson of the association, said healthcare practitioners were unaccountably under restriction and “walking on eggshells” because of the predominant climate of distrust and hostility from medical aid schemes. He said that overall the issue is the fight over money – patients’ money. All the disagreements that will be placed before the investigating panel are, in the final analysis and reduced to a fight over financial interests.

Norman Mabasa, board member and former chair of the SA Medical Association (Sama), spoke anecdotally regarding a black gynaecologist in Giyani, Limpopo, who performed Caesarean sections in 2003 at a time when they weren’t widely done, was investigated by a big medical scheme for fraud, as other doctors weren’t billing and doing the same procedure.

Doctor organizations, made submissions at the hearings, charged that medical aid schemes and their administrators were abusing section 59 and acted as “prosecutors and judges” while investigating fraud, waste and abuse. They said that they had no legal order to carry such investigations.

The Health Professions Council of SA –has 187 000 registered practitioners and its analytics data showed that though it had more African practitioners registered, it had received more complaints from white registered practitioners. They more likely complained because of their levels of education and affluence.

Earlier this year, the Council for Medical Schemes summoned a summit on fraud, waste and abuse in the industry, which would cost between R22 billion and R25 billion a year. At the summit private practitioners defended themselves against the commonly held narrative that it was doctors motivating fraud and waste. They instead said it was the “medical aid schemes themselves that were acting as laws unto themselves through unlawful investigation”.

Gumede also said that he had heard of schemes calling the spouses of medical practitioners and inquiring what time their partners got home from work. They also questioned about how practitioners can see as many as 30 patients a day.

Elijah Nkosi – chief executive of the Independent Practitioners’ Association Foundation – representing 5 000 doctors – said that even though it might be hard to prove these allegations, one has to look at the demographics and geographical bases of the practices “targeted” for the “forensic examinations” to see that they were in “historically black population-based areas”.

The panel, led by Advocate Tembeka Ngcukaitobi SC, will make recommendations to the Council for Medical Schemes to address the complaints and with proper administrative, lawful and policy interventions.