Medical aid complaint letter: template for the scheme and the CMS

Use it when a claim was rejected, a co-payment looks wrong, a waiting period or late joiner penalty was applied incorrectly, or the scheme has not answered you. If the problem is a single rejected claim, the appeal letter is the sharper tool. Use this complaint when the issue is bigger or the appeal failed.

This process is for medical schemes, their administrators, managed care organisations and brokers. Gap cover and hospital cash plans are insurance products, not medical schemes. Complain to the insurer first, and then to the National Financial Ombud, not the CMS.

[Your full name]
[ID number]
[Membership number]
[Cellphone] | [Email]
[Date]

To: The Complaints Department
[Scheme name]

Subject: Formal complaint - membership number [MEMBERSHIP NUMBER]

Dear Sir or Madam

I am lodging a formal complaint.

What happened: [DESCRIBE IN TWO OR THREE SENTENCES, WITH DATES, CLAIM OR AUTHORISATION NUMBERS AND AMOUNTS].

Why I believe this is wrong: [NAME THE BENEFIT, SCHEME RULE OR PRESCRIBED MINIMUM BENEFIT YOU RELY ON].

What I am asking for: [THE OUTCOME, FOR EXAMPLE THE CLAIM PAID IN FULL, THE CO-PAYMENT REVERSED, OR A WRITTEN EXPLANATION WITH THE RULE THAT APPLIES].

I attach: [LIST YOUR DOCUMENTS].

Please reply in writing by [DATE], and give me a complaint 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]

The CMS wants a fully completed complaint form with a detailed account of the facts in dispute and the outcome you want. It also asks for proof that you first tried to resolve the matter with the scheme. The current form is on the CMS site. Send this letter with it.

[Your full name]
[ID number]
[Membership number and benefit option]
[Cellphone] | [Email]
[Date]

To: The Registrar's Office, Complaints
[Council for Medical Schemes](/guides/council-for-medical-schemes-complaints/)

Subject: Complaint against [SCHEME NAME] - membership number [MEMBERSHIP NUMBER]

Dear Sir or Madam

I attach my completed complaint form against [SCHEME NAME].

Summary: [ONE OR TWO SENTENCES].

Steps I took with the scheme: I complained on [DATE], reference [SCHEME REFERENCE]. The scheme replied on [DATE] with [SUMMARY OF ITS ANSWER] / has not replied.

Outcome I am asking for: [FOR EXAMPLE, A REVIEW OF THE REJECTION AND PAYMENT OF THE CLAIM].

I attach: the complaint form, my complaint to the scheme, the scheme's reply, and [CLAIM STATEMENTS, ACCOUNTS AND CLINICAL REPORTS].

Yours faithfully
[Full name]

• To the scheme: the claim or account, the rejection letter, any rule you rely on, and the authorisation number if there was one.
• To the CMS: the completed form, proof of your earlier complaint to the scheme, the scheme's reply, and clinical reports or account statements where they matter.
• If someone else lodges the complaint for you, a consent letter from you. The CMS asks for it.

Put your full name, membership number, benefit option and contact details on everything.

Email the scheme letter to the complaints or disputes address on its website, and save the sent copy. Ask for a reference number. Send the CMS complaint to [email protected], or deliver it by hand or by post to 420 Witch-Hazel Avenue, Eco Park, Centurion. Keep the sent email or the postal slip.

The CMS Customer Care Centre gives telephone advice on 0861 123 267 or +27 12 431 0500, Monday to Friday, 08:00 to 16:30. Complain as soon as you cannot resolve the matter with the scheme, and preferably within 3 years.

Scheme: we could not verify a fixed number of days the scheme has to answer, or a waiting time you must sit out before you may go to the CMS. Ask for a reasonable date in your letter and follow up in writing.

CMS, according to its complaints page:

Clinically urgent complaints are handled urgently. If you disagree with a decision of the Registrar, an appeal under Section 48 must be lodged by affidavit within 3 months of the decision. In 2024/25 the CMS registered 1 962 complaints and resolved 1 879. The CMS complaints guide explains each step.

The strongest complaints point to a clear rule. Prescribed minimum benefits must be paid in full without co-payments or deductibles, an emergency treated at the nearest facility must be covered, and a member who was forced to use a non-DSP provider should not pay a penalty. See prescribed minimum benefits and the PMB letter.

Mistakes to avoid:

• Going to the CMS before using the scheme's complaints process.
• Writing a long story with no dates, claim numbers or amounts.
• Not saying what outcome you want.
• Leaving out the scheme's reply, or proof that you complained.
• Stopping your contributions during the dispute, which can end your cover.