Legal assistance for medical aid complainants

2014-09-07 15:00

Multimedia   ·   User Galleries   ·   News in Pictures Send us your pictures  ·  Send us your stories

Consumers have always been able to take complaints against their medical schemes to the Council for Medical Schemes, but it has typically been a case of David and Goliath because consumers do not have access to a legal team and often lose cases on appeal.

To remedy this imbalance, the CMS has introduced a mediation process and is now able to offer complainants pro bono legal assistance.

The mediation process and legal assistance are just two arms of a programme designed by the CMS to encourage medical scheme members to be more active in engaging with their medical schemes and raising complaints that need to be addressed.

Free legal advice

If you have raised a complaint about a medical scheme with the CMS and you are unhappy with the ruling, you have always had the right to lodge an appeal against the ruling.

But this was not necessarily assisting members because medical schemes could also appeal if the ruling went against them, according to Stephen

Mmatli, the CMS’s head of investigations and compliance. He said this was because medical schemes were often represented by attorneys and counsel at appeal hearings, and members who could not afford the same legal services were at a disadvantage.

In a bid to balance the appeal process, the CMS is now working with probono.org to offer you free legal assistance.

“We’ve already found that medical schemes that previously rushed to appeal rulings are now hesitating because they are aware the complainant will also have legal counsel at hand,” said Mmatli.

He added that when medical schemes employ legal counsel to fight decisions on appeal, the costs for the legal counsel are actually borne by you, the member, through your scheme fees.

Mediation process

A pilot project was introduced between March and July last year during which members and schemes voluntarily participated in an alternative dispute resolution process or mediation. Mediation can be introduced after the registrar of the CMS has made a ruling and before a complaint is set down for hearing by the CMS appeals committee. Of the 21 cases that were referred to mediation during the pilot project, 15 were settled between the parties.

Make yourself heard

»?You should always try to resolve a complaint directly with your medical scheme before you take the complaint to the CMS. But if you are not satisfied with their response, you can escalate it to the CMS.

»?You can send a complaint to the CMS via email, fax or by post. You can download a complaint form from the CMS website at www.medicalschemes.com

» The CMS will send you a written acknowledgement of your complaint within three working days, which will include a reference number as well as the name and contact details of the person who will be dealing with your complaint. Make sure you note the reference number so that staff are able to quickly call up your complaint when you call them for feedback on progress with your complaint.

»?The medical scheme then has 30 days to send the CMS a response to your complaint. Decisions or rulings are then made by the CMS within 120 days or three months after receiving your complaint.

Join the conversation!

24.com encourages commentary submitted via MyNews24. Contributions of 200 words or more will be considered for publication.

We reserve editorial discretion to decide what will be published.
Read our comments policy for guidelines on contributions.

24.com publishes all comments posted on articles provided that they adhere to our Comments Policy. Should you wish to report a comment for editorial review, please do so by clicking the 'Report Comment' button to the right of each comment.

Comment on this story
0 comments
Comments have been closed for this article.

Inside News24

 
/News

Book flights

Compare, Book, Fly

Traffic Alerts
There are new stories on the homepage. Click here to see them.
 
English
Afrikaans
isiZulu

Hello 

Create Profile

Creating your profile will enable you to submit photos and stories to get published on News24.


Please provide a username for your profile page:

This username must be unique, cannot be edited and will be used in the URL to your profile page across the entire 24.com network.

Settings

Location Settings

News24 allows you to edit the display of certain components based on a location. If you wish to personalise the page based on your preferences, please select a location for each component and click "Submit" in order for the changes to take affect.




Facebook Sign-In

Hi News addict,

Join the News24 Community to be involved in breaking the news.

Log in with Facebook to comment and personalise news, weather and listings.