Legal assistance for medical aid complainants

2014-09-07 15:00

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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 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

» 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.

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