Managed healthcare: Treatment protocols and fiduciary duties of funders

Abstract

Managed healthcare has become the cornerstone of health service delivery in the private sector in South Africa  and the world over. As a result, managed care organizations and medical aid schemes have had to draw up recommended treatment protocols in accordance with the rules and regulations of the Council for Medical Schemes (CMS). T he protocols are rigid, do not always consider each case on its own merit and do not always benefit the members of the respective schemes .  The purpose of the  protocols is  to determine which treatment options constitute essential medical care, costeffective treatment and which ones do not. The article examines the fiduciary duties of the medical aids and the existing relationship between the managed healthcare company and the members in a trustee-beneficiary duty of loyalty.