The Council for Medical Schemes (CMS), which is the regulator for medical schemes in South Africa, has initiated new processes to put more power in your hands so that you are able to take on large medical schemes.

Consumers have always been able to take complaints against their medical schemes to the CMS, but it has typically been a case of David vs Goliath because consumers don’t 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.

Both the mediation process and the pro bono legal assistance are just two arms of a programme designed by the CMS to encourage medical scheme members to be more active in terms of 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 not happy with the ruling, you have always had the right to lodge an appeal against the ruling. This, however, was not necessarily assisting members because medical schemes could also appeal if the ruling went against them and, as Stephen Mmatli, head of investigations and compliance points out, the fact that medical schemes are often represented by attorneys and counsel at appeal hearings means that members who cannot afford the same legal services are at a disadvantage.

In a bid to balance the appeal process, the CMS is working together with ProBono.Org to offer you free legal assistance. “We’ve already found that medical schemes who previously rushed to appeal rulings are now hesitating because they are aware that the complainant will also have legal counsel at hand,” says Mmatli. He also points out 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.

How to 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 via the CMS website.
• The CMS will send you a written acknowledgement of your complaint within three working days and this 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 of having received your complaint.

Prescribed minimum benefits (PMBs)

The CMS received 5 609 complaints last year, down 10.9% from the year before. One of the main reasons for the decline in complaints is that medical practitioners who were complaining to the CMS regarding schemes that were not paying accounts on time have been asked to engage with the relevant schemes directly. Most complaints (2 116) related to the short payment of prescribed minimum benefits (PMBs). Acting registrar of the CMS, Dr Daniel Lehutjo, says the provision that entitles members and beneficiaries of medical schemes to PMBs is the most striking feature of the Medical Schemes Act. “This guarantee protects members against health events which could otherwise result in financial ruin,” he says.

A number of medical schemes have been declining PMB claims on the grounds that members did not use the agreed facility or a government facility for procedures or to get their medication. This is usually known as the designated service provider or DSP. However, if it is an emergency or you are involved in an accident, you have to be treated at the nearest health facility regardless of whether it is a DSP or not – and your scheme has to pay for the treatment you receive. Similarly, if the DSP is unable to treat you or provide the medicine you need for your PMB, then the medical scheme has to pay the costs of your treatment or your medication received via a different healthcare provider.

The actual cost of PMBs per beneficiary per month last year worked out to an average of R512.80. The most prevalent PMB condition was hypertension (high blood pressure), followed by hyperlipidaemia (high cholesterol), type 2 diabetes and asthma.

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