The Council for Medical Schemes  

South Africans are lucky to be able to choose between more than a hundred different medical schemes. Private medical care and the provision of medical cover is a massive industry in South Africa.

There are more than eight and a half million members of the various schemes and these members pay more than eighty four billion rand towards their medical cover each year. It is clear that such a large industry needs some regulation and the millions of members need to be protected against poor services and fraud. This watchdog role is fulfilled by the Council for Medical Schemes.

The council was established in 1998 as a statutory body and the sole aim of the council is to regulate the private healthcare industry.

Formation of the council

The council is governed by a board that is appointed by the Minister of Health and it consists of fifteen members. The board also include the positions of non-executive president and deputy chairman that are part-time positions. These positions are filled every three years. This board is known as the Council. It meets at least four times a year but there are often more regular meetings.

The members are not necessarily from a medical background. In fact, the members are generally from diverse backgrounds, ranging from legal experts to corporate management professionals. The board is responsible to formulate policy and to suggest legislative changes. 

There is also an executive committee of the council that oversees the day to day functioning of the council. This committee meets on a monthly basis and they are responsible for communicating with the public, the media and all other stake holders. 

The chief executive, also known as the Registrar, oversees the management team that consist of executive managers. The registrar is appointed by the Minister of Health.

What are the duties of the Council? 

· It has to look after the interests of both the medical schemes and the members of the various schemes.

• The council must monitor the solvency percentage and financial health of all medical schemes.
• It must investigate all complaints and they play an important role in dispute resolution.
• It collects data relevant to the private health care system and it makes information available to stake holders.
• It makes sure that all schemes adhere to national policies that apply to them.
• The council has the responsibility to interpret the Medical Schemes Act and to subsequently draw up rules, guidelines and policies that must be followed by the medical schemes.
• The council keeps the Minister of Health informed on all matters relating to the private health care industry and it makes suggestion to the Minister about legislative issues.
• The council must make sure that the public is informed about their various rights and they must take steps to ensure that those rights are honoured by the medical aid schemes. 

How to lodge a complaint against a medical scheme 

The investigation of complaints is one of the most important functions of the Council for Medical Schemes. It is always better to first attempt to solve a problem with the relevant scheme directly, but any member of any scheme is entitled to lodge a complaint with the council. The council will inform the scheme when a complaint is received. 

The council has a special complaints investigation team that will be activated when the scheme does not resolve the issue in a satisfactory manner. The complainant does not have to pay any fees in order to have complaints investigated. However, if the findings of the investigation are unsatisfactory to the complainant he may lodge an appeal with the Appeal Board. The decision of this board is final.

Complaints should always be in writing. Full contact details of the Council for Medical Schemes are available on their website: http://www.medicalschemes.com.

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NOTES:

Your medical aid quote will include options to suit your pocket. Please ensure that the cover you select is exactly what you need and that you understand exactly what insurance you are buying. Do not hesitate to ask questions about the medical aid or hospital cover you choose.