Medical Aid Scheme Complaints

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Medical Aid Scheme Complaints

Often, only when the need arises - sometimes this is a little too late - do we ask or attempt to read about the procedures to be followed when laying a complaint about the Medical Aid Schemes. The South African law allows for statutory bodies to be formed that deal with consumer’s desires, worries or expectation when coming to the Medical Aid Schemes.

One such body is, The Council for Medical Schemes

The Council for Medical Schemes is a statutory body established by the Medical Schemes Act (131 of 1998) to provide regulatory supervision of private health financing through medical schemes.

The governance of the Council is vested in a board appointed by the Minister of Health, consisting of a Non-executive Chairman, Deputy Chairman and 13 members. The Executive Head of the Council is the Registrar, also appointed by the Minister in terms of the Medical Schemes Act. The Council determines overall policy, but day to day decisions and management of staff are the responsibility of the Registrar and the Executive Managers.

The Council for Medical Schemes supervises a massive and very important industry: There are about 124 (41 open and 83 restricted) medical schemes and growing in South Africa with around 7.1 million and growing beneficiaries. These schemes have a total annual contribution flow of about R 57, 6 billion which grows each year.

Who sits on the Council?

Members of the Council represent a variety of skills and backgrounds, and include experts in law, finance, actuarial sciences, economics, medical sciences, corporate governance and consumer affairs. Council members are appointed on a part-time basis for a period of up to 3 years.

The Minister appoints a chairperson to the Council. Currently, Professor William Pick is the Chairperson - He is the past President of the Medical Research Council, and retired from active work. Professor Pick brings considerable skills in a number of key areas, including corporate governance, understanding of health policy, medicine and leadership.

Role of the Council for Medical Schemes

  • To protect the interests of medical schemes and their members;

  • To monitor the solvency and financial soundness of medical schemes;

  • To control and co-ordinate the functioning of medical schemes in a manner that is complementary with the national health policy;

  • To investigate complaints and settle disputes in relation to the affairs of medical schemes

  • To collect and disseminates information about private health care in South Africa

  • To make rules (that are in line with the Medical Schemes Act) with regard to its own functions and powers; and

  • To make recommendations to the Minister of Health on criteria for the measurement of quality and outcomes of the relevant health services provided for by medical schemes.

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    Medical Schemes: Where To Complain

    Got a problem with your medical scheme, hospital, doctor, dentist, nurse, pharmacist or optometrist? Here's where to go for advice and complaints.

    Council of Medical Schemes is the one to call. Their web site has a "complaints zone" where a complaint can be both filed and tracked online. Before submitting a complaint, you must first follow your medical scheme's internal complaints procedure though.

    Another body one could contact is, Health Professions Council of South Africa (HPCSA). A statutory body that sets and maintains standards for health care in the country. Every health professional must be registered with the Council, which has the power to institute a disciplinary inquiry into any complaint of unprofessional conduct by any of its members. Note that the Council however does not handle complaints against hospitals. HPCSA could be contacted at, Tel: (012) 338 9300 or 328 6680 and Fax: (012) 328 5120/4895

    Hospital Complaints. Complaints against public hospitals should be made with the Department of Health. Complaints against private hospitals should be lodged with the Hospital Association of South Africa. Contact details, Tel: (012) 312 000 and Fax: (012) 326 4395

    One could also try, The South African Medical Association on Tel: (012) 481 2000 and Fax (012) 481 2100

    Another organisation that regulate and monitor different medical professions in South Africa are, South African Nursing Council, an independent statutory body that sets and maintains nursing standards in South Africa, and investigates complaints of unprofessional conduct by nurses.  This body could be contacted at Tel: (012) 420 1000 and Fax: (012) 343 5400

    Dental Ombudsman for complaints and questions about treatments or charges contactable at 0860 110 725 with South African Dental Association at Tel: (011) 484 5288 and 0860 11 3334 or Fax: (011) 642-5718

    South African Optometric Association will assist with complaints against optometrists who are members of the Association. They are contactable at Tel: (011) 805 4517 or Fax: (011) 805 3882

    In terms of the different pharmacies, South African Pharmacy Council contactable at Tel: (012) 319 8500 or Fax: (012) 321 1492

    Recently there has been a scourge of Medical Aids refusing payments for certain treatments of patients and other ailments. It is up to the member to study the terms and conditions of their respective Medical Aid Scheme to understand what is and what is not covered, if any questions or uncertainties, the bodies mentioned above could be of major help.