Managing medical aids

When you are diagnosed with cancer your specialist doctor must discuss treatment options with you, explaining the procedures, and drugs, that could be used and their side effects. This is called informed consent and is a legal requirement. You and your doctor will then agree on your treatment. This becomes your treatment plan.

Having agreed on a treatment plan, your medical aid must be informed. Your doctor will submit your treatment plan to your medical aid for them to agree to pay for the treatment. Your medical aid will respond to your doctor stating which part/s of your treatment plan they agree to pay for. This normally takes a few days.

Your medical aid might accept the entire treatment plan, in which case you can begin your treatment, OR the medical aid might decline part, or all, of your treatment plan. If this happens your doctor can either change your treatment plan or you can challenge your medical aid’s decision.

Challenging Your Medical Aid’s Decision

  • Gather as much information about the benefits offered on your medical aid plan. Look in brochures, newsletters, members’ guides, their website and your medical aid contract. If you don’t have this information, call your medical aid and ask for it, you have a legal right to this information and your medical aid MUST provide it.
  • Get a copy of the letter that your medical aid sent to your doctor denying your treatment plan. The letter from the medical aid should list the following: The reason why they denied your treatment plan, Who made the decision – their name, position, qualifications and authority to make such a decision, The protocol, clinical evidence or medical aid rule that allowed them to deny your treatment.
  • Ask your doctor to help you write a letter of complaint to your medical aid’s Principle Officer requesting that they investigate the denial of your treatment plan.
  • Be very specific and include a full description of why your complaint should be considered.
  • Medical aids have a legal obligation to explain why they are denying your treatment plan. If any of the information listed in point 2 was not provided in writing when they denied your treatment plan you should ask for it.
  • The Principle Officer will investigate your complaint and take the matter up with the Administrator of your medical aid.
  • The Principle Officer will decide on your complaint and must respond in writing.
  • If you are satisfied with the Principle Officer’s response the matter is closed and you and your doctor can decide on the next steps of your treatment OR If you are NOT satisfied you can challenge the Principle Officer’s decision.

Challenging the Principle Officer’s Decision

You can lodge an appeal with your medical aid. All medical aids should have Dispute Committees to ensure that complaints are heard.

  • Send a letter to the same Principle Officer requesting that they refer the matter to the Dispute Committee.
  • The Dispute Committee will investigate your complaint and respond with a final written answer on your matter.
  • You can accept the committee’s findings OR If you are NOT satisfied with their response you can submit an appeal to the Council for Medical Schemes (CMS). Appeals to the CMS must be made within 3 months of your medical aid’s Disputes Committee decision.

Appealing to the CMS

You can lodge a complaint with the Council for Medical Schemes.

Complaint forms are available from www.medicalschemes.com/Content.aspx?110

Complaints can be submitted:

  • In person – Monday to Friday (08h00 – 17h00) – Hadefields Office Park, Block E, 1267 Pretorius Street, Hatfield.
  • Or posted to Private Bag X34, Hatfield, 0028
  • Or faxed to 012-430-7644 mark it For The Attention Of: Complaints Division, Council For Medical Schemes
  • Or emailed to complaints@medicalschemes.com

Call 0861-123-267 or 012-431-0500 to follow-up on your complaint.

Adapted from a www.campaign4cancer.co.za article.

For more on the promotion and protection of your rights with regard to policy, healthcare costs and healthcare delivery visit

www.campaign4cancer.co.za or call Dot on 082-878-1348.

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