Resolving Medical Aid Disputes
We pride ourselves in resolving any issues or complaints with you internally. However, we know sometimes things can go wrong even with the best intentions. So, if you have been through our internal channels and are still not happy with the outcome, you can escalate the complaint to the Registrar’s office of the Council for Medical Schemes (CMS).
Bonitas: Our contacts for queries or complaints
We are here to support you and provide the best care available so you can focus on getting better. That’s why we’re here for you in difficult times. For this reason, we have a general queries and customer complaints line. Please don’t forget to 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 firstname.lastname@example.org
When do I escalate my claim to the Registrar’s office?
If you have already complained to us and are unhappy with the outcome, call 0860 002 108 or email email@example.com and request that your query be escalated to the CMS. You will need to have your reference number handy when doing this. Please remember that at the request of the CMS, they will not get involved in the matter unless members of all medical aid schemes go through the complaints and escalation channels available internally with their medical aid scheme.
How can I lodge a complaint or dispute with the Registrar of CMS?
Complaints can be submitted by letter, fax, email, or in person at the CMS offices from Mondays to Fridays during 08:00 – 17:00. Please click here to download the complaint form. For further information on the CMS, visit www.medicalschemes.com
How will the CMS help me?
The CMS governs the medical schemes industry, which means it can facilitate unresolved complaints about your medical scheme. If your complaint is related to any other aspect of the health industry, please follow the links below:
- For complaints against Health Professionals (doctors) – www.hpcsa.co.za
- For complaints against Private Hospitals – www.hasa.co.za
- For complaints against Nurses – www.sanc.co.za
- For complaints against Brokers – www.faisombud.co.za
The CMS procedure
The CMS is not on anyone’s side. They provide a transparent, accessible, swift as well as a reasonable and procedurally fair dispute resolution process. The steps below are followed:
- 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
- Within 4 days of receiving the complaint from the administrator, the Registrar’s Office will analyse the complaint and refer a complaint to a medical scheme for comments
- 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
- 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)
Can I appeal to the CMS against the Registrar’s Ruling?
- 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.
The Section 50 Appeal’s process
- 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 is payable for Section 50 Appeals