Medical Aid Plan - Medical Aid Claim Dispute Resolution

Medical Aid 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. A medical aid claim dispute becomes inevitable.

Medical Aid Claim Dispute ResolutionMost medical aid 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 as possible. 

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 disputes will be handled immediately and as a matter of priority. Of course, members are entitled to appoint professionals such as attorneys to handle 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: 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 documents.

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 Medical Schemes? 

  • Within three days after lodging your complain the council will send an acknowledgement from the Council with a reference number and the details of the specific individual dealing with your complaint.
  • The Council will investigate the complaint and ask your medical scheme for input and comments.
  • Once the reaction of the scheme is received a ruling is made and both parties are informed accordingly.
  • If you are not happy with the ruling you have the right to appeal to the Appeals Committee within thirty days of receiving the ruling.
  • 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 Plan



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