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SmartAboutMoney reports that about 2,000 medical scheme members complained about denied claims and other medical scheme issues last year and the Council for Medical Schemes (CHS) found in favour of more than 50% of the complainants.
This resulted in many members' claims being paid, or paid more fully. But many other members' complaints were dismissed because the council found that their schemes had applied scheme rules correctly. In such cases, members often did not know or understand the benefits their schemes provided. The council's latest annual report for 2023/24 shows that while many claims were paid, substantial sums were paid from members' pockets. The CMS noted "a gap in beneficiaries' understanding of commonly used concepts in the medical scheme industry" such as pre-authorisation, treatment protocols, formulary, and scheme tariffs. This was particularly noticeable in open schemes, which were responsible for nearly three quarters of all the complaints. The council dealt with more than 500 complaints about prescribed minimum benefits (PMBs), which schemes are obliged by law to provide. The largest category of complaints was those the council classified as administrative. The council dealt with more than 1,000 complaints relating to the payment of benefits, pre-authorisation, customer service, medical savings accounts, contributions and benefit option changes. The CMS noted a concerning increase in complaints where medical schemes failed to address member queries timeously, resulting in those matters being escalated to the council. It also said schemes failed to inform members of their internal dispute resolution committees and clinical appeal processes.
- Read the full original of the report in the above regard by Laura du Preez at Fin24 (subscription or trial registration required)
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