Council for medical schemes complaint

Any beneficiary or any person who is aggrieved with the conduct of a medical scheme can submit a complaint.

It is however very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the Council for assistance.

Who can complain to the Council for Medical Schemes (CMS)?

Any person who is aggrieved by the conduct of a person or entity that is registered or accredited in terms of the Medical Schemes Act may lodge a complaint.

Is the complaint valid? (Also referred to as justiciable complaint)

A complaint will be deemed justiciable or valid if the entity/person complained against is alleged to have:

• acted, or failed to act, in contravention of the Act; or
• acted improperly in relation to any matter which falls within the jurisdiction of the Council.

Complaints adjudication processes

Before approaching the Council for Medical Schemes, complainants must ensure that they first exhaust internal dispute resolution processes at the medical scheme / regulated entity. This will ensure speedy resolution of the complaint and enable the CMS to determine if internal escalations at these entities are effective.

If the complainant is not satisfied with the outcome of the escalation / dispute resolution process, the complaint may be referred to the CMS for investigation. Click here to access the complaint form.

The following documents must be submitted to enable timely registration of the complaint:

• A fully completed Complaint Form, with a detailed account of the complaint/ facts in dispute and desired recourse.
• Proof of prior escalation with the medical scheme / regulated entity.
• If the complaint is submitted by third party, the beneficiary / member must provide a signed letter of consent.
• If the dispute involves clinical elements, all relevant clinical reports must be attached.
• If the dispute relates to unpaid/short paid claims, copies of account statements must be attached.
• Other relevant supporting documents.

Complainants are encouraged to submit their complaints as soon as they are unable to reach a resolution with the medical scheme / regulated entity. This must preferably be within a 3-year period.

Complaints must be submitted to the complaints mailbox complaints@medicalschemes.co.za

Alternatively, the complaint may be hand delivered at CMS offices