Medical savings account query and refund letter

Use it when:

• a PMB or registered chronic claim came off your savings or day-to-day benefit;
• a claim was paid from savings after you had already paid the provider yourself and claimed it back;
• the same claim was paid twice;
• you are leaving the scheme and want to know how your savings balance will be handled.

The medical savings account guide explains how savings work. For claims that were not paid at all, use the claim submission letter or the appeal letter.

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

To: The Claims / Member Accounts Department
[Scheme name]

Subject: [Medical savings account](/guides/medical-savings-account/) query - membership number [MEMBERSHIP NUMBER]

Dear Sir or Madam

Please review the following deduction from my medical savings account.

Claim number: [CLAIM NUMBER]
Patient: [NAME AND DEPENDANT CODE]
Date of service: [DATE]
Provider: [PROVIDER]
Amount taken from savings: R[AMOUNT]

Reason for my query (keep the one that applies):
- This is a prescribed minimum benefit or registered chronic condition (ICD-10 code [CODE]) and should be paid in full, not from my savings.
- I paid this provider myself and the claim was then also paid from my savings, so it appears to be paid twice.
- I am leaving the scheme on [DATE] and ask how my savings balance will be handled and when.

Please correct the allocation, restore the amount to my savings or refund it to:
Bank: [BANK]
Account holder: [NAME]
Account number: [ACCOUNT NUMBER]
Branch code: [BRANCH CODE]

Please reply in writing by [DATE] with a reference number, and tell me which scheme rule you rely on if you do not agree.

Yours faithfully
[Full name]
[Signature]

• The statement page or claim history showing the deduction.
• The detailed account for the claim.
• Proof that you paid the provider yourself, if the query is about a double payment.
• For a PMB or chronic query, the doctor's letter showing the diagnosis and ICD-10 code.
• Your bank details, in the letter.

Circle or highlight the line in question. It saves the scheme a search.

Email it to the claims or member accounts address on your scheme's website, or use the query option in the app or portal. Save the sent copy, note the date and ask for a reference number. If you phone, note the name, the time and the reference. Keep every statement until the query is closed.

Regulation 8(1) says every benefit option must pay the diagnosis, treatment and care costs of the PMB conditions in full, without a co-payment or deductible. If a PMB claim is coming off savings, ask why. The usual cause is that the condition is not registered as chronic, or the code on the claim does not match the diagnosis.

The scheme can still require its DSP, pre-authorisation, protocols and formularies, and can charge a co-payment if you use a non-DSP by choice. It cannot do so if the use was involuntary, for example in an emergency. See prescribed minimum benefits, the PMB letter and the chronic medication letter.

We found no national rule in the sources we checked on whether a savings balance is refunded, transferred or carried over when you leave. It depends on your scheme's rules, so ask in writing. Some schemes advertise that unused savings carry over to the next year and earn interest, but that is a plan feature, not a universal right.

Do not assume a positive balance will reach you. Keep your bank details up to date with the scheme, and ask when a refund would be paid. Use the cancellation letter to ask for the answer at the same time.

Ask whether anything is owing by you before you leave.

We found no national deadline for the scheme to answer a savings query, so ask for a reply date and follow up in writing. If the answer is unfair or missing, complain to the scheme and then the Council for Medical Schemes. Use the complaint letter. The CMS Customer Care Centre gives advice on 0861 123 267.

Common mistakes:

• Querying without the claim number, date or amount.
• Not saying whether the claim was a PMB, chronic or a double payment.
• Leaving out your bank details, so a refund cannot be paid.
• Waiting until after you leave the scheme to ask about the balance.
• Not keeping the reference number.