Any matter that a member of a medical scheme is not satisfied with can qualify as a complaint. Examples are:
The following are usually not good disputes (very slim chance for success):
Any person can lodge a complaint and any person can represent a member at a complaint or appeal hearing hearing. This can be yourself, your broker, a MedCare ADR practitioner or any other person such as an attorney.
The first step is that you must submit the complaint in writing. The CMS now only accept an electronic submission via the website. However, you can attach supporting documents and additional comment.
Once a complaint is submitted the registrar will give the medical scheme 30-days to respond. Depending on the circumstances you will also then get an opportunity to respond to the medical schemes reply whereafter the registrar will make a decision.
Lodging a frivolous complaint will serve no purpose. Every complaint has its own challenges. However, there are some rules that you can apply. Preparation is the most important requirement. The following guidelines can be given:
A dispute will take anything from 1 – 3 months to be heard and adjudicated. There are exceptions to this timeline.
You can lodge a complaint yourself and you can represent yourself. However, you can also use your broker or a MedCare ADR practitioner. You can also use an attorney but that will be expensive.
No, the registrar is not permitted to make a cost order regarding a complaint. You must fund your own cost, as well as the cost of witnesses or people that represent you.
Yes, but any aggrieved party (You or the medical scheme) may appeal to the appeal council in terms of section 48 of the Medical Schemes Act. The appeal must be in the form of an affidavit, and it must be submitted not later than three months after the registrar’s decision was made.
Yes, you may institute legal action. We suggest that is the last route that you consider as it is costly to institute legal proceedings. If you dispute matters or lodge complaints, you do not forfeit any rights to institute legal action at a later stage.
No, you do not need to. However, lodging a dispute first have 2 advantages. Firstly, it may be quicker. Secondly, it gives another layer of resolving the matter.
If you approach the CMS first, you will need to prove that you attempted to resolve the matter with the medical scheme first.