Medical Aid Scheme Complaints

Facing issues with your medical aid provider? Whether it's claim delays, benefit rejections, or poor service, understanding your options is crucial.

Common Medical Aid Complaints

• Claim delays or non-payment of valid claims
• Benefit exclusions—when your claim is denied due to policy terms
• End-of-year limits being reached early
• Incorrect billing or unexpected co-payments
• Poor customer service and lack of communication

Steps to Resolve Medical Aid Disputes

1. Review your policy to understand benefits and exclusions
2. Contact your scheme’s member services with clear details and evidence
3. Keep written records of all communication and reference numbers
4. Request escalation if the issue isn't resolved within reasonable time
5. If unresolved, lodge a formal complaint with the Council for Medical Schemes (CMS)

How to Lodge a Complaint with the CMS

The Council for Medical Schemes is the official regulator for private medical aids in South Africa. If internal efforts fail, the CMS can investigate your case and facilitate resolution. You can submit complaints online via the CMS website, by email, or by post.

When to Seek Independent Help

Some issues require external support. You may want to engage:

• A healthcare consultant or broker specializing in dispute mediation
• A legal advisor for serious breaches or illegal conduct
• An ombudsman for professional guidance or arbitration

Tips to Prevent Medical Aid Complaints

• Understand your policy’s inclusions, limits, and exclusions
• Submit accurate documentation with every claim
• Track your authorisations and claims online or via app
• Ask questions early if you're unsure about benefit cover

Get Help with Your Medical Aid Complaints

Connect with experienced healthcare consultants who specialize in resolving medical aid disputes.

Appoint A Medical Aid Consultant Here