Benefits & claims
How to claim from your medical aid
By MedicalAidZA editorial team · 8 min read · Updated 29 September 2026
- Direct claim
- Provider claims from the scheme; you pay any co-payment or shortfall
- Pay and claim back
- You pay, then submit an itemised account and proof of payment
- Emergencies
- A scheme may not stop a provider starting emergency treatment before authorisation
- Complaints
- Scheme first, then the CMS: [email protected], 0861 123 267
Most medical aid claims are sent straight to your scheme by the hospital, doctor or pharmacy, so you do nothing except pay any co-payment. When you pay upfront instead, you submit an itemised account and proof of payment, and the scheme refunds the covered part into your bank account.
Claims go wrong in a few predictable ways: no pre-authorisation, a missing detail on the account, a benefit that has run out, or a provider outside the network. This guide covers the two routes, how to submit through the main scheme apps, the authorisation lines for four large schemes, what to do when a claim is short-paid or rejected, and how to escalate to the Council for Medical Schemes (CMS).
Claim deadlines are set by each scheme's rules. We did not find a single verified deadline that applies to all schemes, so we do not quote one. Check your own scheme's rules and submit as early as you can.
Direct claims and pay-and-claim-back
There are two routes, and your plan may use both.
- Direct claim. The hospital, specialist or pharmacy sends the account to your scheme and is paid directly. You pay only the co-payment, any amount above the scheme tariff and anything not covered. This is the usual route for hospitals and many doctors.
- Pay and claim back. You pay the provider, then submit the account and proof of payment. The scheme refunds the covered portion to your nominated bank account.
Some products pay differently. Oneplan, a health insurer and not a medical scheme, pays claims onto a pre-loaded Oneplan Claim Card. If your day-to-day cover comes from a product like that, read its claim rules separately.
How to submit a claim yourself
- Get an itemised account, not just a till slip. It should show the provider, the date, the service or tariff codes and the amount.
- Have your membership number and dependant code ready.
- Submit it through your scheme's app, member portal or email, with proof of payment.
- Keep a copy and note the date you submitted it. If a claim is later called late, that record is your evidence.
- Check the claims statement to see what was paid, what was short-paid and why.
Many schemes let you photograph an account in the app. LA Health members use the Discovery app to submit claims by photographing them with a smartphone camera, and Remedi's app accepts claims submitted with a photo.
Submitting through the scheme apps
Apps that state a claims feature in the scheme's own information:
| Scheme | App | Claims and authorisation features |
|---|---|---|
| Discovery Health Medical Scheme | Discovery Health app | Manage providers, claims, benefits and balances |
| Momentum Health | Momentum App | Submit and track claims, get pre-authorisation |
| Bestmed | Bestmed App | Submit claims, check available benefits |
| Medihelp | Medihelp app | Authorise hospital admissions, submit and track claims |
| Fedhealth | Fedhealth Member App | Make claims, request authorisations |
| Profmed | Profmed App | Submit claims, see benefit limits, claim statements |
| CompCare | Universal.one App | Claim submission and tracking, hospital pre-authorisation requests |
| Sasolmed (restricted scheme) | Sasolmed web app | Track claims and limits, upload claims |
| Anglo Medical Scheme (restricted scheme) | Anglo Medical Scheme app | Standard Care and Managed Care members can submit and track claims |
| Umvuzo (restricted scheme) | Umvuzo Health Mobile App | Statements, claims history, authorisation requests |
Not every scheme lists a claims feature. GEMS's member app, for example, is described for updating personal details and showing the membership e-card, so check the scheme's website or call centre for how to claim. Contact details for every scheme are on our medical aid contact numbers page.
Pre-authorisation and emergencies
Planned hospital admissions and certain procedures need approval before the date. The scheme gives you an authorisation number and tells you any co-payment. Without it you can face a penalty or a rejected claim, even for care the scheme would otherwise have paid. Our pre-authorisation guide has the detail.
| Scheme | How to request hospital authorisation |
|---|---|
| Discovery Health Medical Scheme | 0860 99 88 77 (07:00 to 20:00 Mon to Fri, 08:00 to 13:00 Sat) |
| Bonitas | 0860 002 108 or [email protected] |
| Bestmed | [email protected] |
| Medihelp | [email protected] |
Emergencies work differently. The regulations say a scheme may not prohibit a provider from starting appropriate treatment for an emergency medical condition before authorisation, so treatment comes first. Tell the scheme afterwards. Genesis asks that the hospital or member notifies it on the first working day after an emergency admission, and Cape Medical Plan says emergency admissions must be authorised within 72 hours. See emergency and ambulance cover.
Claim deadlines
Every scheme sets a time limit in its rules for submitting claims. A late claim can be refused even if the treatment was covered. We did not find a verified single deadline across schemes, and the figure is different from scheme to scheme, so look it up in your scheme's rules or on the claims page, and submit within weeks rather than waiting.
If a scheme says you were late and you submitted in time, your dated proof of submission is the evidence. Ask for the claim reference number when you submit by email or through the app.
Why claims are short-paid or rejected
| Reason on the statement | What it usually means | What to do |
|---|---|---|
| No authorisation | A planned admission or procedure was not approved first | Ask the scheme to authorise retrospectively and explain the circumstances |
| Non-DSP or non-network provider | You used a provider other than the one the scheme designated | For a PMB, the scheme cannot charge a co-payment if the use was involuntary, for example the DSP could not treat you without unreasonable delay or none was within reasonable distance |
| Benefit exhausted | The limit or savings for that category is used up | Check the benefit schedule and your balance |
| Above scheme tariff | The provider charged more than the scheme pays | Ask the provider to accept the tariff or ask about gap cover |
| Waiting period or exclusion | The benefit is not yet available or is excluded | Check the rules. Exclusions do not apply to PMBs |
| Formulary or protocol | The medicine or treatment was not on the scheme's list | Ask your doctor about an alternative or motivate an exception |
| Missing information | Codes, dates or an itemised account were missing | Correct and resubmit |
A Prescribed Minimum Benefit must be paid in full without co-payment or deductible when you follow the scheme's rules, although schemes may use pre-authorisation, protocols and formularies. Read designated service providers and co-payments and sub-limits.
How to dispute a rejected claim
- Read the reason on the claims statement and ask the scheme for the clinical or rule basis in writing.
- Send a written dispute through the scheme's internal dispute process, with the account, the statement, any doctor's motivation and reference numbers. Use our appeal a rejected claim letter or the claim submission letter.
- Escalate to the CMS if that fails. The CMS requires that you first exhaust the scheme's internal process, then send a completed complaint form and proof of that escalation to [email protected]. Its Customer Care line is 0861 123 267.
The CMS says it acknowledges a complaint within 6 working days and aims to resolve it within 120 calendar days from receiving the scheme's response and documents. Submit preferably within 3 years. An appeal against a Registrar decision must be lodged by affidavit within 3 months. See complaints to the CMS.
Claims on gap cover and other insurance
Gap cover claims are made after your medical scheme has paid. A medical expense shortfall policy covers the difference between the total cost and what your scheme paid, and from 1 April 2026 its maximum benefit is R226 881.03 per insured person per year. Gap cover is insurance, so complaints about it go to the National Financial Ombud, not the CMS. Read gap cover explained before you buy.
Frequently asked questions
How do I claim from my medical aid?
Most providers claim directly from the scheme. If you pay yourself, get an itemised account, submit it with proof of payment through your scheme app, portal or email, and the scheme refunds the covered portion to your bank account.
Do I need pre-authorisation for every claim?
No. Planned hospital admissions and certain procedures need it, and GP visits generally do not. In an emergency, treatment can start before authorisation and you inform the scheme afterwards.
How long do I have to submit a claim?
Each scheme sets its own deadline in its rules, so check yours. Submit as soon as you can and keep proof of the date you submitted.
Why was my claim rejected?
Common reasons are no authorisation, a provider outside the network, an exhausted benefit, a waiting period, a formulary or protocol issue or missing information on the account. The claims statement gives the reason, and you can dispute it in writing.
Can I be charged a co-payment on a PMB?
A Prescribed Minimum Benefit must be paid in full without a co-payment when you follow the scheme rules. A co-payment can apply if you voluntarily use a provider other than the designated one, but not if the use was involuntary.
Who do I complain to about a rejected claim?
Use your scheme's internal dispute process first. If it does not resolve the matter, send a completed complaint form and proof of escalation to the CMS at [email protected] or call 0861 123 267.
Do I claim gap cover from my scheme?
No. Gap cover is a separate insurance policy that pays after your scheme has paid, covering part of the difference between the total cost and the scheme payment. From 1 April 2026 it is capped at R226 881.03 per insured person per year, and complaints about it go to the National Financial Ombud.
