Any matter that a member of a medical scheme is not satisfied with can qualify as a complaint. Examples are:

• Non-payment of a Prescribed Minimum Benefit (PMB)
• Short payment of a PMB
• Where a PMB was paid using a members personal medical savings account (MSA)
• Not allowing a deviation from a protocol (Treatment plan) if the existing protocol is ineffective cause or would cause harm to a specific beneficiary
• Not allowing a deviation from a formulary (medication) if the existing protocol is ineffective cause or would cause harm to a specific beneficiary.
• Not applying regulation 8(3) correctly in terms of involuntary use of a Designated Service Provider (DSP)
• Imposing a waiting period incorrectly
• Waiting periods or late joiner penalties (LJP) incorrectly applied.
• etc

The following are usually not good disputes (very slim chance for success):

• Benefits that are excluded
• LJP correctly applied
• Waiting periods correctly applied
• Benefit limits exhausted such as a limit for dental treatment
• Credible coverage of non-South Africa registered medical schemes refused Etc

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:

• What does the Medical Schemes Act state about the dispute?
• What does the Regulations state about the dispute?
• What does the Circulars or practice notes published by the Registrar of Medical schemes state about the dispute?
• What does your medical scheme’s registered rules state about the dispute? Did you check the main rules, the annexures that deal with exclusions, PMB’s and the specific option?
• What did the appeal council and appeal board decide in similar cases?
• Is there clinical support for your dispute? (Does your medical practitioner support the clinical necessity, and will he or she testify on your behalf?)
• Why would it be fair that the dispute be decided in your favour?
• Do you have any case law or evidence-based medicine argument that will support your dispute?

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.