Medical Aid Claims Dispute Resolution

January 17, 2013

I have never personally been part of a medical aid claims dispute resolution. And in all honesty I never want to be either. What is a claims dispute and how does one resolve a dispute that might arise? In laymen’s terms, a dispute is when you disagree with something. And a resolution is the ruling on such a dispute.

Dealing with claims

Medical aids in South Africa usually try their utmost to deal with claims disputes efficiently without them having to be taken further. Discovery medical aid, and others, insist that their members first approach them in the case of a dispute. Then, if a consultant cannot resolve your dispute, they will refer you to a senior consultant that can.

YoClaims Dispute Resolutionu may approach your own legal representative to deal with the dispute directly with your medical aid but this could be costly and is not always necessary. Your medical aid would rather take the time to sort  out your dispute amicably. That is preferable to having a dissatisfied member.

Should you or your legal representation still not be happy with the result, then you may approach the Council of Medical Schemes that governs the medical schemes industry by one of the following means:

Physical address

Postal address

Hadefields Office Park, Block E

1267 Pretorius Street

Hatfield

0028Private Bag X34

Hatfield

0028

Complaints Customer Care Service Centre

(012) 431 0608 Fax Complaints or

Email complaints@medicalschemes.com

0861 123 267

Claims Dispute Resolution

It is preferable always to first try and resolve your dispute with your medical aid before going to the Council for Medical Schemes (CMS) and you can do this in a number of ways.

One can download a complaint form from the Councils website on www.medicalschemes.com and submit it to them. Or you can visit their offices, fax, email or post them your complaint on the above addresses.

What happens once a complaint is lodged?

  • The council will acknowledge, in writing that they have received your complaint and will issue you with a reference number, the person dealing with your complaint as well as the name of your complaint. You should receive this acknowledgment within three days of your making the complaint. 
  • The council then assesses your claim and sends the complaint to your scheme for comment.
  • Once a response has been received a ruling will be made and then conveyed to all parties involved in the dispute.
  • Should you not be satisfied with the ruling you are allowed to appeal the decision with the Appeals Committee and this needs to be done within 30days of receiving the ruling.
  • The date and time for the hearing of the appeal will be sent to you and it is at this hearing where evidence from both parties to substantiate claims will be heard. 
  • A final decision will then be made and presented to you.
  • If your dispute is really of such a nature that after this process you are still not completely satisfied with the outcome, then you are then entitled to approach the Appeals Board which is called the Section 50 Appeal’s process. There is a prescribed fee of R2000 should you wish to go this route. 

 

I am of the opinion that it would be far easier to resolve the dispute with your medical scheme than to spend more than three months going through the Council’s process.

All info was correct at time of publishing