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The Complaints Procedure

Who can complain to the Registrar’s Office?

Any beneficiary or any person who is aggrieved with the conduct of a medical scheme can submit a complaint.

It is however very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the Council for assistance.

Complaints can be submitted to the CMS by filling in the online form. Click the button below for online submission.

Who can you complain about?

The Council for Medical Schemes governs the medical schemes industry and therefore your complaint should be related to your medical scheme.

If your complaint is related to any other aspect of the health industry, please follow the links below:

Submit a Complaint Online/Check your Complaint Status

Time limits for dealing with complaints:

Our aim is to serve the beneficiaries of medical schemes and the public by investigating and resolving complaints in an effective and efficient manner. By doing this, we ensure that beneficiaries are treated fairly by their medical schemes.

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.

The Registrar’s Office shall within 4 working days of acknowledging the complaint, analyse the complaint and refer to the regulated entity 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 regulated entity for a written response. The entity complained against is obliged to provide a written response to the Registrar’s Office within 30 days.

Where valid reasons are provided for not meeting the 30 days’ timeframe, the Registrar may grant an extension of deadline. Upon receipt of the response, the Registrar’s Office will analyse the response, gather the required evidence and conduct all the necessary investigations to ensure a fair and balanced decision or ruling.

Decisions / rulings will be issued and communicated to the parties within 120 working days after receipt of all the relevant documentation / evidence

Where this timeline cannot be met due to complexity of investigations, the Registrar will endeavour to keep complainants updated of developments and reasons for delayed resolution.

Limits to powers of the Registrar:

The Registrar is may only issue rulings or directives within the scope of the Medical Schemes Act. The following forms of relief cannot be made by the Registrar:

  • Award punitive damages or compensation for delays, pain and suffering;
  • Order full refund of contributions, unless provided for in the registered rules of a medical scheme;
  • Direct payment of health expenses which are lawfully excluded from benefits in terms of the Act;
  • Payment of interest;
  • Dismiss or discipline employees of a regulated entity.

Appeal Process

The Section 48 Appeal process

  • Any person aggrieved by any decision relating to the settlement of a complaint may appeal against such a decision to Council.
  • This appeal is at no cost to either of the parties.
  • Any decision which is the subject of an appeal shall be suspended pending review of the matter by the Council’s Appeal Committee.
  • An appeal lodged under Section 48 must be in the form of an affidavit, within 3 months after the date on which the decision was made. The Council may condone late submission of an appeal, on good cause shown.
  • The 3-month period for lodging appeals is legislated in the Act, therefore the Registrar has no powers to shorten the period or condone late submission.
  • 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 rescind it and give another decision as they seem just.

The Section 49 Appeal process

  • Section 49 of the Act makes provision for any party who is aggrieved with the decision of the Registrar to appeal such a decision.
  • Decisions which may be appealed under Section 49 are those where the Registrar is carrying out duties imposed by the Act or exercising powers conferred by the Act
  • 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. The operation of the decision shall 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 rescind it and give another decision as they seem just.

The Section 50 Appeal’s process

  • Any party that is aggrieved with the decision of the Appeals Committee may appeal to the Appeal Board.
  • The aggrieved 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 shall determine the date, time and venue for the hearing and all parties will be notified in writing.
  • Appeal Board shall be heard in public unless the chairperson decides otherwise.
  • The Appeal Board shall have the powers which the High Court has to summon witnesses, to cause an oath or affirmation to be administered by them, to examine them, and to call for the production of 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 R2800.00 is payable for Section 50 Appeals

Click to view the latest judgments on appeals

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