Medical Aid rules are complicated and there is often misunderstanding and disagreement between the scheme administrator and the member. You should know that when a medical aid refuses to pay for a benefit that you feel you are entitled to, there are a lot of recourses for you to sort out the matter.
Escalate within the scheme
Always start by speaking to your scheme. Put all your communication in writing.
Some schemes will have an appointed person who deals with escalated queries or complaints. If your complaint is not resolved to your satisfaction, ask your scheme if the matter can be escalated.
Make use of your broker
If you do not come right with your scheme on your own, it is time to turn to your broker. There is no charge to you to appoint a broker.
A broker will help you determine whether you have a valid claim against your medical aid, and might even try to sort out the matter on your behalf.
Lay a complaint with the Council
As a last resort, you can contact the Council of Medical Schemes. This is “a statutory body established by the Medical Schemes Act to provide regulatory supervision of private health financing through medical schemes“.
The Council regulates all schemes, and you can submit a complaint to them at any time. Put all your communication in writing, and ensure that you submit all relevant information, including copies of all correspondence between you and your scheme. You can send this by registered post, or you can email it to firstname.lastname@example.org.
You can also visit the Council of Medical Scheme’s website, or call them on 0861 123 267.