How to complain to the Council for Medical Schemes

The Council for Medical Schemes (CMS) is the regulator. Under section 47 of the Medical Schemes Act you can complain to it, in writing, about a matter covered by the Act. You can do this yourself, and it costs nothing to lodge a complaint.

Step 1: use the scheme’s own process first

Every scheme has an internal dispute process in its rules. Lodge your dispute in writing, say exactly what you want (for example “pay claim X in full as a PMB”), and keep proof that you sent it. Schemes are expected to resolve disputes within a set time. Ask them what theirs is.

Step 2: lodge a complaint with the CMS

If the dispute is not resolved, send the CMS a written complaint. It helps to include:

• Your name, ID number, scheme and membership number.
• A short, dated timeline of what happened.
• Copies of the claim statements, invoices and clinical letters.
• Your dispute letter and the scheme’s reply.
• The specific outcome you want.

If someone else lodges the complaint for you, the CMS needs your signed letter of consent allowing them to act.

What happens next

The CMS publishes its own service targets: acknowledging a complaint within about six working days, asking the scheme to respond within 30 days, and issuing a ruling within about 120 working days of receiving all the documents. These are targets, so expect to wait months, and answer any follow-up questions quickly.

If you disagree with the ruling

The CMS ruling can be appealed. The appeal route and deadlines are set out on the CMS site, so check them as soon as you receive the ruling, because time limits apply.

Current forms and contact details are on the CMS complaints procedure page.