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 110 medical schemes in South Africa with around 8 068 505 beneficiaries. These schemes have a total annual contribution flow of about R84.9 billion.
The Registrar will investigate complaints against medical schemes. Prior to submitting a complaint to the Council, it should be submitted to the relevant medical scheme and only if the person is dissatisfied with the outcome should a complaint be made to the Council.
Persons dissatisfied with the decision of the Registrar can lodge an appeal with the Appeal Board. A prescribed fee is payable for the appeal process.
The service is free to consumers
Customer Care Service Center
0861 123 267
0861 123 cms
Telephone: (012) 431 0500
Fax: (012) 430 7644
Fax Complaints: (012) 431-0608
The complaints procedure
Who can complain to the Registrar’s Office?
Any beneficiary or any person who is aggrieved with the conduct of a medical scheme can submit a complaint.
It is however very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the Council for assistance.
Complaints can be submitted by any reasonable means such as a letter, fax, e-mail or in person at our Offices from Mondays to Fridays during 08:00 – 17:00
Who can you complaint about?
The Council for Medical Schemes governs the medical schemes industry and therefore your complaint should be related to your medical scheme.
If your complaint is related to any other aspect of the health industry, please follow the links below:
- For complaints against Health Professionals (doctors) – www.hpcsa.co.za
- For complaints against Private Hospitals – www.hasa.co.za
- For complaints against Nurses – www.sanc.co.za
- For complaints against Brokers – www.faisombud.co.za
- For complaints in respect of other health insurance products – www.osti.co.za (short term insurance ombudsman) or www.ombud.co.za (long term insurance ombudsman)
Time limits for dealing with complaints:
Our aim is to provide a transparent, equitable, accessible, expeditious as well as a reasonable and procedurally fair dispute resolution process.
The Registrar’s Office will send a written acknowledgement of a complaint within 3 working days of its receipt, providing the name, reference number and contact details of the person who will be dealing with a complaint.
In terms of Section 47 of the Medical Schemes Act 131 of 1998 a written complaint received in relation to any matter provided for in this Act will be referred to the medical scheme. The medical scheme is obliged to provide a written response to the Registrar’s Office within 30 days.
The Registrar’s Office shall within 4 days of receiving the complaint from the administrator, analyse the complaint and refer a complaint to a medical scheme for comments.
Upon receipt of the response from the medical scheme, the Registrar’s Office will analyse the response in order to make a decision of ruling. Decisions / rulings will be made within 120 days of the date of referral of a complaint and communicated to the parties.
The Registrar’s Ruling and appeal to Council:
Section 49 of the Act makes provision for any party who is aggrieved with the decision of the Registrar to appeal such a decision.
This appeal is at no cost to either of the parties.
An appeal must be lodged within 30 days of the date of the decision. The operation of the decision shall be suspended pending review of the matter by the Council’s Appeal Committee.
The secretariat of the Appeals Committee will inform all parties involved of the date and time of the hearing. This notice should be provided no less than 14 days before the date of the hearing.
The parties may appear before the Committee and tender evidence or submit written arguments or explanations in person or through a representative.
The Appeals Committee may after the hearing confirm or vary the decision concerned or rescind it and give another decision as they seem just.
The Section 50 Appeal’s process:
Any party that is aggrieved with the decision of the Appeals Committee may appeal to the Appeal Board.
The aggrieved party has 60 days within which to appeal the decision and must submit written arguments or explanation of the grounds of his or her appeal.
The Appeal Board shall determine the date, time and venue for the hearing and all parties will be notified in writing.
Appeal Board shall be heard in public unless the chairperson decides otherwise.
The Appeal Board shall have the powers which the High Court has to summon witnesses, to cause an oath or affirmation to be administered by them, to examine them, and to call for the production of books, documents and objects.
The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties.
The prescribed fee of R2000.00 is payable for Section 50 Appeals.