How to report a medical aid scheme for wrongdoing
How to report a medical aid scheme for wrongdoing in South Africa revealed.
We verified how to report a medical aid scheme for wrongdoing in South Africa.
This is a complete guide to reporting a medical aid scheme for wrongdoing.
In this in-depth guide you’ll learn:
- What is a Medical Aid Scheme?
- What is the medical ombudsman?
- What is the council for medical schemes?
- What are the medical board complaints?
- When should you report medical aid wrongdoing?
- Where do you report medical aid for wrongdoing?
So if you’re ready to go “all in” with reporting a medical aid scheme for wrongdoing in South Africa, this guide is for you.
Let’s dive right in…
How to report a medical aid scheme for wrongdoing Summary
How medical schemes are governed in South Africa
👉 In accordance with the Medical Schemes Act (131 of 1998), the Council for Medical Schemes is a statutory entity that was established for the purpose of providing regulatory supervision of private health funding carried out through medical schemes.
👉 The Minister of Health is the one who appoints the members of the board, which includes a Non-executive Chairman, Deputy Chairman, and 13 other members. This board is responsible for the governance of the Council.
👉 According to the Medical Schemes Act, the Minister is also responsible for appointing the Registrar, who serves as the executive head of the Council. The Registrar and the Executive Managers are responsible for making day-to-day decisions as well as managing the personnel. The Council is responsible for setting general policy.
👉 The Council is responsible for overseeing a huge and critically significant industry that is comprised of over 80 medical plans that are registered in the country.
The Medical Schemes Act 131 of 1998
👉 The Medical Schemes Act has the following purposes:
➡️ To bring together the laws that pertain to registered medical schemes;
➡️ To make provision for the establishment of the Council for Medical Schemes as a juristic person;
➡️ To make provision for the appointment of the Registrar of Medical Schemes;
➡️ To make provision for the registration and control of certain activities of medical schemes;
➡️ To protect the interests of members of medical schemes;
➡️ To make provision for measures for the coordination of medical schemes;
➡️ To make provision for incidental medical matters.
How one can report the conduct of a medical scheme
👉 Complaints about the conduct of a medical scheme can be filed by anybody, including beneficiaries of a medical plan as well as anyone else who is dissatisfied with the way the plan was administered.
👉 Because the Council for Medical Schemes (CMS) is the governing body for the industry of medical schemes, your complaint ought to be directly related to the actions or performance of your medical scheme.
👉 A very important point to keep in mind is to always make an effort to settle the problem through the complaints mechanisms that are in place at the medical scheme in question before turning to the Council for help.
Learn more about Dischem Medical Aid Plans
The Complaints Procedure
👉 To file a complaint with the CMS, you can simply complete out the form that can be found on their website and submit the complaint manually or online.
How to submit a complaint manually
👉 To submit a manual complaint, you can download the form from the council’s website (https://www.medicalschemes.co.za/consumer-assistance/complaintsprocedure) and submit it together with all available supporting documents to [email protected].
👉 You can also post it to The Council for Medical Schemes: Complaints Unit, Private Bag X34, Hatfield, 0028.
Time limits for complaints
👉 The council’s aim is to serve the beneficiaries of medical schemes and the public by investigating and resolving complaints in an effective and efficient manner. By doing this, it ensures that beneficiaries are treated fairly by their medical schemes.
👉 Within three business days of receiving a complaint, the Registrar’s Office will send a formal acknowledgement of the complaint. This acknowledgement will include the name, reference number, and contact information of the person who will be handling the complaint.
👉 Within four business days of acknowledging the complaint, the Registrar’s Office is required to conduct an analysis of the complaint and then submit the matter to the regulated entity for comments.
👉 A written complaint that is received with respect to any topic that is provided for in this Act will be sent to the regulated entity so that they can provide a written response in accordance with the provisions of Section 47 of the Medical Schemes Act 131 of 1998.
👉 Within a month after receiving the complaint, the party that is the subject of the complaint is required to provide a written answer to the Registrar’s Office.
👉 If the Registrar is presented with convincing evidence that explains why the 30-day deadline could not be met, they have the authority to extend the deadline. Following the receipt of the response, the Registrar’s Office will do an analysis of the response, as well as acquire the needed evidence and carry out all of the necessary investigations, in order to guarantee a judgement or conclusion that is fair and balanced.
👉 Within one hundred and twenty workdays after receiving all of the pertinent material and proof, decisions and rulings will be issued and conveyed to the parties.
👉 In the event that this deadline is unable to be fulfilled due to the complexity of investigations, the Registrar will make every effort to keep complainants informed of developments and the reasons for the delay in resolving the issue.
Everything you need to know about the “Medical Aid Ombudsman”
👉 The medical aid ombudsman is a body that individuals can approach for redress concerning a variety of concerns that pertain to their medical aid scheme or service provider, as well as any other issue that is associated with their medical aid.
👉 This can also include the final service providers that are either contracted through that particular medical aid or who are a part of the medical aid system in question.
👉 One further way to think about the medical aid ombudsman is as a kind of big brother who is there to look out for your best interests and make sure that any problems that arise with your medical insurance plan are resolved in a way that is above board, legal, and ethical.
👉 In this role, the medical aid ombudsman will make sure that any concerns that arise may be resolved. In the past, there was not a designated medical ombudsman in the same manner that there were other ombudsmen in place to handle other concerns such as misuse or abuse of authority, government corruption, and so on.
👉 In this way, the Medical Aid Scheme Council of South Africa serves in a role similar to that of a collective ombudsman.
👉 It is an extremely important body because it basically has to oversee and regulate around ninety-seven or so medical aid scheme service providers operating in South Africa, collectively over eight million beneficiaries, and this entire industry is worth billions of rand.
👉 The Council for medical schemes is the governing body of all of South Africa’s medical aid schemes and service providers. With such a vast business there is a very evident need to have an all-encompassing regulating organisation in place to ensure that all is above board and that beneficiaries have legal redress in the form of the council for medical plans.
👉 This is basically the closest thing there is to a medical aid ombudsman, and it is actually a very successful and well-organized agency.
👉 You could be wondering how exactly this council for medical plans can be of use to you at this point, and the response is actually fairly straightforward and easy to understand. Because of the way that the council is established, it is possible for anyone who has a grievance regarding their medical assistance programme to go to the council in order to seek some form of redress.
👉 There is no limitation or specification as to the kinds of problems that a person can complain about or seek remedy over, thus virtually any problem that you may have can be brought to the council’s attention for resolution.
👉 If you are feeling aggrieved by your medical aid service provider, then you should approach the council.
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Frequently Asked Questions
Where can I report a medical scheme in South Africa?
To report wrongdoing or complaints regarding a medical aid scheme in South Africa, you can contact the Council for Medical Schemes (CMS). The CMS is the regulatory body responsible for overseeing medical schemes in the country
How can you report your medical aid if you are unhappy about its actions?
Before approaching the Council for assistance, a potential complainant should always make an effort to settle their problem through the complaints mechanisms that are in place at the medical scheme in question before turning to the Council for help. To file a complaint with the CMS, simply complete out the form that can be found on their website.
How do you report a medical aid complaint in writing?
When you report a complaint in writing, you need to include the following information in your Letter:
- An address and contact detail where you can be reached
- Your email address, if sending by email
- The important dates relevant to the issue
- Give the basic facts for your complaint in a short, factual summary
- Attach any documents you may have as evidence
- Tell the council how you already tried to resolve the problem.
- Be reasonable.
- File your complaint.
In what ways can you contact the medical Ombudsman?
You can contact the medical ombudsman on Toll-Free Number 080 911 6472; Fax 086 560 4157; email [email protected], post Private Bag X 21, Arcadia, Pretoria, 0007, or walk-in at OHSC Offices, 79 Steve Biko Road, Prinshof, Pretoria.
What can you do if your medical aid refuses to pay a claim?
If your medical aid refuses to pay a claim, you can ask your doctor to provide a motivation with valid reasons as to why the treatment is necessary. In certain cases, a medical aid may then reconsider covering the treatment in question. You can collect a motivation letter from your doctor and send it through to the scheme so that their medical panel can reconsider the decision.