RESOLVING MEDICAL AID DISPUTES
We pride ourselves in resolving any issues or complaints with members internally. However, if you are still dissatisfied with the outcome, complaints can be escalated to the Registrar’s office of the Council for Medical Schemes (CMS).
We are here to support you and provide the best care available that so you can focus on getting better. That’s why we are here to support you through difficult times. For this reason we have a general queries and customer complaints line. Please ensure you make a note of the reference number of your query as you will need this when following up.
General queries and customer complaints:
- Phone 0860 002 108
- Email email@example.com
If you have already complained to us and are unhappy with the outcome, call 0860 002 108 or email firstname.lastname@example.org and request that your query be escalated to the CMS. You will need to cite the reference number you received when doing so.
The CMS has requested that disputes only be resolved through them AFTER you have gone through the complaints and escalation channels available through your medical aid.
Complaints can be submitted by letter, fax, e-mail or in person at the CMS offices from Mondays to Fridays during 08:00 – 17:00. For details of the offices, contact numbers, email addresses, etc. Please click here to download the complaint form.
For further information on CMS, visit www.medicalschemes.com
The Council for Medical Schemes governs the medical schemes industry which means it facilitates unresolved complaints about your medical scheme.
If your complaint is related to any other aspect of the health industry, please follow the links below:
CMS aims to provide a transparent, fair, accessible, swift as well as a reasonable and procedurally fair dispute resolution process.
- Step one: The Registrar’s Office will send a written acknowledgement of a complaint within 3 working days of its receipt, providing the name, reference number and contact details of the person who will be dealing with a complaint
- Step two: The Registrar’s Office will, within 4 days of receiving the complaint from the administrator, analyse the complaint and refer a complaint to a medical scheme for comments
- Step three: In terms of Section 47 of the Medical Schemes Act 131 of 1998 a written complaint received in relation to any matter provided for in this Act, will be referred to the medical scheme. The medical scheme is obliged to provide a written response to the Registrar’s Office within 30 days
- Step four: When the response is received from the Medical Scheme, the Registrar’s Office will analyse the response in order to make a ruling. Decisions/ rulings will be made and communicated to the parties within 120 days of the date of referral of a complaint (refer step two)
- Yes, Section 49 of the Act allows any party who is unhappy with the decision of the Registrar to appeal the decision
- This appeal is at no cost to either of the parties
- An appeal must be lodged within 30 days of the date of the decision (step 4 outlined above). The action related to the decision will be suspended pending review of the matter by the Council’s Appeal Committee
- The Secretariat of the Appeals Committee will inform all parties involved of the date and time of the hearing. This notice should be provided no less than 14 days before the date of the hearing
- The parties may appear before the Committee and tender evidence or submit written arguments or explanations in person or through a representative.
The Appeals Committee may, after the hearing, confirm or vary the decision concerned or overturn it and give another decision.
- If you are unhappy with the decision of the Appeals’ Committee you may appeal to the Appeal Board
- Either party has 60 days within which to appeal the decision and must submit written arguments or explanation of the grounds of his or her appeal
- The Appeal Board will determine the date, time and venue for the hearing and all parties will be notified in writing
- The Appeal Board shall be heard in public unless the chairperson decides otherwise
- The Appeal Board has the same powers as the High Court: To summon witnesses under oath or affirmation, to examine them and to call for evidence though books, documents and objects
- The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties
- The prescribed fee of R2000.00 is payable for Section 50 Appeals
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