Legal action is expensive. The term alternative dispute resolution (ADR) refers to a procedure, agreed to by conflicting parties of a dispute, in which they use the services of a neutral party to assist them in reaching agreement and avoiding costly litigation.
Section 29(1) (j) of the Medical Schemes Act compels medical schemes to contain the process how members can resolve complaints and/or disputes. Section 47 to 50 of the Medical Schemes Act also allow aggrieved parties to lodge complaints with the Registrar of Medical Schemes and allow for appeals if an aggrieved party is dissatisfied with a decision or ruling.
Any matter that a member of a medical scheme is not satisfied with can qualify as a dispute. Examples are:
The following are usually not good disputes (very slim chance for success):
Any person can lodge a dispute and any person can represent a member at a dispute hearing. This can be yourself, your broker, a MedCare ADR practitioner or any other person such as an attorney.
There is unfortunately not one process. However, there are some common processes:
Therefore, it is important that the rules of your specific medical scheme be followed.
Lodging a frivolous dispute will serve no purpose. Every dispute 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:
You can lodge the complaint yourself and you can represent yourself. However, you can also use your broker or a MedCare ADR practitioner.
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.
A dispute will take anything up to 3 months to be heard and adjudicated. There are exceptions to this timeline.
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.