Claim Dispute Resolution
Nobody in his right mind likes conflict but it is an unfortunate fact that disputes do occur
between medical schemes and their members.
Most disputes are about claims issues. These
involve cases where claims are refused or members are expected to pay a portion of the cost of treatment. In
many cases disputes occur simply because members have not studies the terms and conditions of their specific
plans. However, medical schemes by and large do everything within their power to resolve disputes as quickly
Some medical aid schemes, such as Discovery Health, insist that members approach them in the
first instance when a dispute arises. They promise members that their disputes will be handled immediately and as a
matter of priority. Of course, members are entitled to appoint professionals such as attorneys to handle their
disputes but this can be a very costly route.
Medical schemes go to great lengths to resolve disputes because they do not want to lose
members and they certainly want to avoid negative publicity. However, any member that is not satisfied with the
outcome of a dispute has the right to approach the Council for Medical Schemes that is a statutory body whose mandate it is to regulate the
private health care industry.
They can be contacted by post, email or even by
telephone and their contact details are available on their website: www.medicalschemes.com. All complaints must be
in writing and it is best to provide as many details about the case as is possible, including copies of supporting
It is certainly best to try and resolve the dispute with the relevant scheme directly, but is a
complaint is directed to the Council for Medical Schemes, it may be a good idea to send a copy of the complaint to
the medical scheme too.You may just achieve results faster.
What happens if you complain to the Council for
- Within three
days after lodging your complain you will receive an acknowledgement from the Council. You will be provided
with a reference number and the details of the specific individual that will be dealing with your
- The Council
will investigate the complaint and they will ask your medical scheme for input and
- Once the
reaction of the scheme is received a ruling is made and both parties are informed
- If you are not
happy with the ruling you have the right to appeal to the Appeals Committee within thirty days of receiving the
- You will be
informed about the time and date of the final hearing and you will have to present additional information or
documentation during that hearing.
- A final
decision is made and you are informed of the result.
- If you are
still not satisfied with the result you have the option to approach the Appeals Board. IN this case, however,
you will have to pay a fee of two thousand rand.
- The ruling of
the Appeals Board is final.
It is always best to try and resolve your medical aid claim dispute resolution in an
amicable manner. However, if you are convinced that your medical scheme is in the wrong, it is comforting to know
that there are independent means of having the complaint investigated. © Medical Aid