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Medical Aid Schemes Complaints
Often, only
when the need arises - sometimes this is a little too late - do we
ask or attempt to read about the procedures to be followed when
laying a complaint about the Medical Aid Schemes. The South African
law allows for statutory bodies to be formed that deal with
consumer’s desires, worries or expectation when coming to the
Medical Aid Schemes.
One such body
is, The Council for Medical Schemes
The Council for
Medical Schemes is a statutory body established by the Medical
Schemes Act (131 of 1998) to provide regulatory supervision of
private health financing through medical schemes.
The governance
of the Council is vested in a board appointed by the Minister of
Health, consisting of a Non-executive Chairman, Deputy Chairman and
13 members. The Executive Head of the Council is the Registrar, also
appointed by the Minister in terms of the Medical Schemes Act. The
Council determines overall policy, but day to day decisions and
management of staff are the responsibility of the Registrar and the
Executive Managers.
The Council for
Medical Schemes supervises a massive and very important industry:
There are about 124 (41 open and 83 restricted) medical schemes and
growing in South Africa with around 7.1 million and growing
beneficiaries. These schemes have a total annual contribution flow
of about R 57, 6 billion which grows each year.
Who sits on the
Council?
Members of the
Council represent a variety of skills and backgrounds, and include
experts in law, finance, actuarial sciences, economics, medical
sciences, corporate governance and consumer affairs. Council members
are appointed on a part-time basis for a period of up to 3 years.
The Minister
appoints a chairperson to the Council. Currently, Professor William
Pick is the Chairperson - He is the past President of the Medical
Research Council, and retired from active work. Professor Pick
brings considerable skills in a number of key areas, including
corporate governance, understanding of health policy, medicine and
leadership.
Role of the
Council for Medical Schemes
·
To
protect the interests of medical schemes and their members;
·
To
monitor the solvency and financial soundness of medical schemes;
·
To
control and co-ordinate the functioning of medical schemes in a
manner that is complementary with the national health policy;
·
To
investigate complaints and settle disputes in relation to the
affairs of medical schemes;
·
To
collect and disseminates information about private health care in
South
Africa
·
To
make rules (that are in line with the Medical Schemes Act) with
regard to its own functions and powers; and
·
To
make recommendations to the Minister of Health on criteria for the
measurement of quality and outcomes of the relevant health services
provided for by medical schemes.
Contact details
Share Call
Number Reception Number is 0861 123 267 or Tel: (012) 431 0500 and
the Fax: (012) 430 7644. Fraud Hotline 082 411 1171
Email
Support
support@medicalschemes.com
Web :
www.medicalschemes.com
/
www.medicalschemes.co.za
Medical
Schemes: Where to complain
Got a problem
with your medical scheme, hospital, doctor, dentist, nurse,
pharmacist or optometrist? Here's where to go for advice and
complaints
Council of
Medical Schemes is the one to call. Their web site has a
"complaints zone" where a complaint can be both filed and tracked
online. Before submitting a complaint, you must first follow your
medical scheme's internal complaints procedure though.
Another body
one could contact is, Health Professions Council of South Africa
(HPCSA). A statutory body that sets and maintains standards for
health care in the country. Every health professional must be
registered with the Council, which has the power to institute a
disciplinary inquiry into any complaint of unprofessional conduct by
any of its members. Note that the Council however does not handle
complaints against hospitals. HPCSA could be contacted at, Tel:
(012) 338 9300 or 328 6680 and Fax: (012) 328 5120/4895
Hospital
Complaints. Complaints against public hospitals should be made
with the Department of Health. Complaints against private hospitals
should be lodged with the Hospital Association of South Africa.
Contact details, Tel: (012) 312 000 and Fax: (012) 326 4395
One could also
try, The South African Medical Association on Tel: (012) 481
2000 and Fax (012) 481 2100
Other
organisation that regulate and monitor different medical professions
in South Africa are, South African Nursing Council, an
independent statutory body that sets and maintains nursing standards
in South Africa, and investigates complaints of unprofessional
conduct by nurses. This body could be contacted at Tel: (012) 420
1000 and Fax: (012) 343 5400
Dental
Ombudsman for complaints and questions about treatments or
charges contactable at 0860 110 725 with South African Dental
Association at Tel: (011) 484 5288 and 0860 11 3334 or Fax: (011)
642-5718
South
African Optometric Association will assist with complaints
against optometrists who are members of the Association. They are
contactable at Tel: (011) 805 4517 or Fax: (011) 805 3882
In terms of the
different pharmacies, South African Pharmacy Council
contactable at Tel: (012) 319 8500 or Fax: (012) 321 1492
Recently there
has been a scourge of Medical Aids refusing payments for certain
treatments of patients and other ailments. It is up to the member to
study the terms and conditions of their respective Medical Aid
Scheme to understand what is and what is not covered, if any
questions or uncertainties, the bodies mentioned above could be of
major help.
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