What do you do if you have a complaint against your medical scheme

Not getting the results you expect from your medical aid? Here is what you can do.

Given the complexities of medical aid plans, the vast number of members many of them have and the multitude of medications and health issues, problems do occur. Sometimes it is a lack of understanding on the part of the member and at times, the medical aid company is wrong.

Some policies are extremely controversial and there are a few occasions where the rules become a bit blurred. It would be great if medical aids could cover all health-related issues sufficiently but this would make the plans unaffordable.

If you understand the terms and conditions of your medical aid and feel that you have a valid complaint, there are a number of ways you can address the issue.

This is the order you should follow:

  • First, address your issue or complaint with the medical aid company through their normal channels.
  • If this does not yield results, you can address your complaint to the Principal Officer in writing, e-mail or telephonically.
  • If the complaint is still not resolved to your satisfaction, you can escalate the matter to the schemes Disputes Committee.
  • The next step, if you are still aggrieved, is to take the matter to the Registrar of Medical Schemes. If you need assistance or advice, the Complaints Adjudication will assist you over the phone or arrange a consultation. They will give the scheme 30 days to respond and then make a ruling that is binding to both the member and the scheme.
  • Following on from that, if you are still not happy you have 30 days to appeal to Council.
  • The last recourse, if all the previous steps have not resolved the issue is to pay a R2000 fee and lodge an appeal with the appeal board. Their decision will be final and if the matter is found in your favour, the fee should be refunded. The decision of the Appeal Board is binding on both parties.

Before proceeding with any action, ensure your contributions are up to date and that you have read and understood the rules and benefits that apply to your scheme and the plan that you selected.