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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.

Who can complain to the Council for Medical Schemes (CMS)?

Any person who is aggrieved by the conduct of a person or entity that is registered or accredited in terms of the Medical Schemes Act may lodge a complaint.

Is the complaint valid? (Also referred to as justiciable complaint)

A complaint will be deemed justiciable or valid if the entity/person complained against is alleged to have:

  • acted, or failed to act, in contravention of the Act; or
  • acted improperly in relation to any matter which falls within the jurisdiction of the Council.

Complaints adjudication processes

Before approaching the Council for Medical Schemes, complainants must ensure that they first exhaust internal dispute resolution processes at the medical scheme / regulated entity. This will ensure speedy resolution of the complaint and enable the CMS to determine if internal escalations at these entities are effective.

If the complainant is not satisfied with the outcome of the escalation / dispute resolution process, the complaint may be referred to the CMS for investigation. Click here to access the complaint form.

The following documents must be submitted to enable timely registration of the complaint:

  • A fully completed Complaint Form, with a detailed account of the complaint/ facts in dispute and desired recourse.
  • Proof of prior escalation with the medical scheme / regulated entity.
  • If the complaint is submitted by third party, the beneficiary / member must provide a signed letter of consent.
  • If the dispute involves clinical elements, all relevant clinical reports must be attached.
  • If the dispute relates to unpaid/short paid claims, copies of account statements must be attached.
  • Other relevant supporting documents.

Complainants are encouraged to submit their complaints as soon as they are unable to reach a resolution with the medical scheme / regulated entity. This must preferably be within a 3-year period.

Complaints must be submitted to the complaints mailbox complaints@medicalschemes.co.za

Alternatively, the complaint may be hand delivered at CMS offices

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:

Who can you complain against?

  • Any person required to be registered or accredited in terms of the Medical Schemes Act or any person whose professional activities are regulated by the Act.

Check here for a list of regulated entities. (medical schemes, managed care organisations, healthcare brokers and administrators)

Complaints related to other institutions within the private healthcare industry:

The Council for Medical Schemes regulates the medical schemes industry and as a result, it can only investigate complaints related to entities who fall within the CMS regulatory mandate.

If your complaint is related to any other “person” in the health industry, please follow the links below to submit your complaint:

Lodge a complaint below

Submit a Complaint Manually

To submit a manual complaint, download the form here and submit it together with your supporting documents to complaints@medicalschemes.co.za  or post it to:

The Council for Medical Schemes: Complaints Adjudication Unit
Private Bag X34
Hatfield
0028

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 which fall within the CMS statutory mandate, within six (6) working days of its receipt, providing the name, reference number and contact details of the person who will be dealing with a complaint.
  • 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 Registrar’s Office shall within four (4) working days of acknowledging the complaint, analyse the complaint and refer to the regulated entity for comments within a period of 30 days.
  • Where the entity fails to respond within the specified period, it may apply for an extension from the Registrar. If 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 decision or ruling.
  • The overall turnaround time for resolution of complaints is 120 calendar days from the date of receipt of the scheme’s response and all supporting documentation.

 

NB! The abovementioned timeframes are not applicable to clinically urgent complaints. These complaints are dealt with on urgent basis.

 

Limits to powers of the Registrar:

The Registrar cannot grant the following forms of relief:

 

  • Award punitive cost orders 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.
  • Employment conditions related to medical schemes.

 

The Registrar may only issue rulings or directives within the scope of the Medical Schemes Act.

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.
  • A prescribed fee, which is gazetted from time to time, is payable for Section 50 appeals.
  • 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.
  • The Appeal Board shall have the powers which the High Court has to summon witnesses, to cause an oath or affirmation to be administered, to examine witnesses, and to call for the production of books, documents, and objects relevant to the appeal.
  • Once there is an appeal the Council’s decision is suspended pending the outcome of Appeal Board proceedings.
  • The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties.

Click to view the latest judgments on appeals

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