Letters
Appeal a rejected medical aid claim or DSP co-payment: letter template
By MedicalAidZA editorial team · 5 min read · Updated 29 September 2026
- Before the CMS
- Use the scheme's internal dispute process first
- CMS acknowledgement
- Within 6 working days
- CMS overall turnaround
- 120 calendar days from the scheme's response and documents
- PMB rule
- Paid in full, no co-payment or deductible (Regulation 8(1))
To appeal a rejected medical aid claim, write to the scheme's disputes department, quote the claim number, name the reason it gave, and explain why that reason is wrong. The copy-paste letter is below.
Get the reason in writing first. You cannot argue against a reason you do not have. The strongest appeals rest on a rule: a prescribed minimum benefit (PMB) that must be paid in full, an emergency, a coding error, or a non-DSP provider you had no real choice about.
If the scheme upholds its decision, you can escalate to the Council for Medical Schemes (CMS).
When to use this letter
Use it after a claim is rejected or short-paid, or when a co-payment is charged for using a provider that is not the scheme's designated service provider (DSP). If you have not yet claimed, use the claim submission letter first.
Ask the scheme for the rejection reason and the rule it relied on. Then match it to a ground in the table below.
Which ground fits your rejection
| What the scheme says | Ground you can raise |
|---|---|
| Not covered or excluded | If the condition is a PMB, exclusions do not apply to PMBs and it must be paid in full |
| Co-payment for a non-DSP | Involuntary use: the DSP could not provide the service without unreasonable delay, immediate treatment was needed where a DSP could not be reached, or no DSP was within reasonable reach |
| Emergency care at any facility | The CMS says you may go to the nearest facility in an emergency, and the scheme must cover the costs |
| Wrong benefit or code | The ICD-10 or tariff code is wrong: ask the provider to correct it and resubmit |
| No pre-authorisation | For an emergency, a scheme may not prohibit a provider from starting treatment before authorisation. Otherwise this may stand |
| Waiting period or late joiner penalty | Check the maximums and the proof of past cover, see the waiting periods guide |
| Benefit or savings used up | This may stand, unless the claim is a PMB |
A co-payment for using a non-DSP by choice usually stands, as the regulations let a scheme impose one.
The appeal letter (copy and paste)
[Your full name]
[ID number]
[Membership number]
[Cellphone] | [Email]
[Date]
To: The Disputes Department
[Scheme name]
Subject: Appeal against rejection - claim number [CLAIM NUMBER], membership number [MEMBERSHIP NUMBER]
Dear Sir or Madam
I appeal against the rejection of the claim below.
Claim number: [CLAIM NUMBER]
Patient: [NAME AND DEPENDANT CODE]
Date of service: [DATE]
Provider: [PROVIDER AND PRACTICE NUMBER]
Amount: R[AMOUNT]
Reason you gave for rejecting it: [QUOTE THE REASON]
Why I dispute it (keep the ones that apply and delete the rest):
- This is a prescribed minimum benefit (ICD-10 code [CODE]) and must be paid in full without a co-payment or deductible.
- This was an emergency, and I went to the nearest facility.
- I could not use the [designated service provider](/guides/designated-service-providers/) because [REASON: NOT AVAILABLE WITHOUT UNREASONABLE DELAY / NO DSP NEAR MY HOME OR WORK / IMMEDIATE TREATMENT NEEDED].
- The code on the claim was wrong. The correct code is [CODE], and the corrected account is attached.
- My doctor's motivation for [MEDICINE OR PROCEDURE] is attached.
What I am asking for: [FOR EXAMPLE, PAYMENT IN FULL / THE CO-PAYMENT REVERSED / A WRITTEN EXPLANATION OF THE RULE].
I attach: the rejection letter, the detailed account and [MOTIVATION, EMERGENCY RECORD OR OTHER PROOF].
Please reply in writing by [DATE] with a dispute reference number. If this is not resolved, I will take it to [the Council for Medical Schemes](/guides/council-for-medical-schemes-complaints/).
Yours faithfully
[Full name]
[Signature]
What to attach
- The rejection letter or remittance advice showing the reason.
- The detailed account, corrected if the code was wrong.
- A doctor's motivation for any medicine or procedure the scheme queried.
- For an emergency, the admission or casualty record. For a DSP dispute, anything that shows the DSP could not help or was not near you.
- The scheme's earlier replies, if you have them.
How to send it and keep proof
Email it to the disputes or complaints address on your scheme's website, or use the dispute option in the app or portal. Save the sent email, ask for a dispute reference number and note the date. If you post it, use registered post.
If you speak to someone, note their name, the time and what they promised. Follow up in writing, quoting the reference number.
What happens next: the scheme, then the CMS
We could not verify a national deadline for the scheme to answer an appeal, so ask for a reply date in your letter. The CMS says you must first exhaust the scheme's internal dispute process before you approach it.
After that, complain to the CMS with a completed complaint form and proof that you escalated with the scheme. The CMS acknowledges within 6 working days, refers the complaint to the scheme for comment, and aims to resolve it within 120 calendar days from receiving the scheme's response and all documents. Urgent clinical complaints are handled urgently. Use the complaint letter and the CMS complaints guide for the next step.
More on the underlying rules is in prescribed minimum benefits and the PMB letter.
Common mistakes
- Appealing without the rejection reason in writing.
- Arguing about unfairness rather than naming a rule.
- Not saying whether a co-payment was for a voluntary or an involuntary non-DSP.
- Leaving out proof, such as an emergency record.
- Sending a story with no claim number or amounts.
- Going to the CMS before the scheme's own process is done.
Frequently asked questions
Can I appeal a rejected medical aid claim?
Yes. Write to the scheme's disputes department, quote the claim number and explain why the reason is wrong. If it upholds the decision, complain to the CMS after finishing the scheme's process.
How do I dispute a DSP co-payment?
Say why the use was involuntary: the DSP could not provide the service without unreasonable delay, immediate treatment was needed where a DSP could not be reached, or there was no DSP within reasonable reach of your home or work. Attach proof.
What are the strongest grounds?
A PMB that was not paid in full, an emergency at the nearest facility, or a wrong ICD-10 or tariff code. These point to clear rules.
How long do I have to appeal?
Your scheme rules may set an internal deadline, and we could not verify a national one. Appeal as soon as you have the reason in writing.
Do exclusions apply to PMBs?
No. The CMS says exclusions do not apply to PMBs, and gives the example of septicaemia after cosmetic surgery, which the scheme must fund.
What if my benefit is used up?
The rejection may be correct for an ordinary benefit. It is not correct for a PMB, which must be paid in full, so check whether the claim was a PMB.
