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:

• 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

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:

• Some medical schemes have a dedicated form that needs to be completed
• Some medical schemes require only that the dispute must be in writing
• Some medical schemes require that the dispute must be in the form of an affidavit.

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:

• 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?

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.