Council for Medical Schemes: how to complain, step by step

The CMS regulates medical schemes, managed care organisations, healthcare brokers and administrators. Any beneficiary or aggrieved person can complain. On its complaints procedure page the CMS also says complaints may be lodged against exempted health insurance providers.

People often search for a "medical aid ombudsman". For a registered medical scheme, the body that handles the complaint is the CMS, not an ombud. Products that are insurance rather than medical schemes go to a different body, covered in the last section.

For a sense of scale, the CMS annual report for 2024/25 records more than 27 000 calls and 10 800 emails to its Customer Care Centre, and more than 80% of complaints finalised within the prescribed timeframes.

The CMS says a complainant must first use the complaints mechanisms at the scheme or regulated entity, and exhaust its internal dispute resolution processes, before approaching the Council.

1. Put your complaint in writing to the scheme. Say what happened, what you want done, and quote your membership number and benefit option.
2. Keep the reference number, the date, the name of the person you spoke to, and every reply.
3. Use the scheme's formal dispute or appeal process if the first answer is a refusal. Your scheme's rules and website explain how.
4. If the answer is still not acceptable, or the scheme does not respond, move to the CMS.

Our medical aid complaint letter and appeal a rejected claim letter give you wording for this stage.

The CMS page does not set a fixed period you must wait at the scheme before you may come to it. What it requires is that you have used the scheme's process and can show proof.

Once the scheme has not resolved it, refer the complaint to the CMS. Send:

• A fully completed complaint form, with a detailed account of the facts in dispute and the outcome you want. The CMS keeps the form on its site, and the current file is the complaint form and checklist.
• Proof that you escalated the complaint with the scheme.
• A consent letter, if someone else lodges the complaint for you.
• Clinical reports or account statements, where they are relevant.

Send it to [email protected], hand deliver it at the CMS offices, or post it. The CMS asks you to submit as soon as you cannot resolve the matter with the scheme, and preferably within 3 years. Write your full names, membership number, benefit option and contact details on everything you send.

The 30 days is the time the scheme gets to respond to the CMS after referral. It is not a waiting period you serve before you can complain. Clinically urgent complaints are handled urgently, so say so plainly and attach the clinical report if your health is at risk.

If the CMS asks for more documents, the 120 days runs from when the scheme's response and supporting documents are complete, so send everything at once.

What it does. It receives the complaint, asks the scheme for its side, and reaches a decision on whether the scheme applied the Medical Schemes Act and its own rules correctly. Disputes people bring include prescribed minimum benefits, co-payments, waiting periods, late joiner penalties, rejected claims and contribution disputes. If you disagree with the Registrar's decision, you can appeal under Section 48.

What it does not do.

• It does not take a complaint that has not been through the scheme's own process first.
• It is not instant. The turnaround is measured in months.
• It only acts on complaints within its mandate. Products that are not medical schemes fall outside it, except exempted providers the CMS itself lists.

Send copies of your documents, never your only originals.

These come from the CMS contact page and complaints procedure page.

The Customer Care Centre also gives telephonic advice before you lodge. The CMS website has a mistyped email link on its complaints page, so type the address above yourself rather than clicking it. For your scheme's own numbers, see our medical aid contact numbers.

Health insurance products are not medical schemes. Gap cover, hospital cash plans and primary care insurance are sold by insurers, and the Council for Medical Schemes is not the body for those complaints. Complain to the insurer first, and if it does not resolve the matter, take it to the National Financial Ombud, which handles complaints about insurers. Check its current contact details before you lodge.

One nuance: the CMS says complaints may also be lodged against exempted health insurance providers. Some primary healthcare and hospital indemnity insurers operate under a CMS exemption, so ask the provider which body applies to your product if it is unclear.

Gap cover has its own annual limit set by Treasury and is covered in gap cover explained. For the difference between the two kinds of product, see medical aid vs health insurance.