How to Get a Medical Aid Claims Dispute Resolution

It seldom happens that you find yourself in a struggle with your medical aid regarding unpaid claims. Should you, however, find yourself there, a medical aid claims dispute resolution is the way forward.

Most medical aid schemes try to settle claims disputes as fast as possible. Firstly, because the disputes can harm the image of the medical scheme; and secondly, a long dispute process is costly for both the scheme and the person causing the dispute.

The steps to follow to place a claims dispute against your medical aid:

• Contact your medical aid and list the dispute. Should a consultant not be able to assist you with the dispute the case will be escalated to a more senior member of their staff. Be sure that you have not broken any of the rules applied to your chosen medical aid plan.
• Should the medical aid be unable to solve your dispute in this way you can contact your legal representative to assist you.
• If the route with your legal representative fails, you can contact the Council of Medical Schemes (CMS). CMS is the governing body of all the medical aids in South Africa. The council is appointed by the Minister of Health and is the closest thing to a medical ombudsman you can find. The council is set up in such a way that any person who has a problem with their medical aid can contact them and find recourse. These problems do not only have to be claims disputes, you can contact them if you feel aggravated with your medical aid too.
• Council of Medical Schemes contact details:

Contact centre: 0861 123 267

Complaints: 012 431 0608 email: complaints@medicalschemes.com

Physical address:
Block A
Eco Glades 2 Office Park
420 Witch-Hazel Avenue  
Eco Park
Centurion
0157

Website:  http://www.medicalschemes.com

What happens when a complaint is laid?

• Within 3 days, the council will contact you in writing that your claim has been received and provide you with a reference number, the name of your complaint and the person dealing with it.
• The claim will then be assessed and sent to your medical scheme to reply.
• When the response is received, the council will make a ruling and notify all the parties involved of their decision.   
• If you are still unhappy you can appeal the results with the Appeals Committee. This has to be done within 30 days of the initial ruling.
• You will receive a date for a hearing where both you and your medical aid will have the opportunity to supply your cases and evidence.
• You will be presented with a final decision.
• If you are still unhappy you can contact the Appeals Board. They do have a subscribed fee of R2 000.

Aside from a resolution with the medical aids themselves, The Council of Medical Schemes is the only alternative way to find a medical aid claims dispute resolution.