Unpaid and short-paid claims
Your scheme paid less than the provider charged, or rejected the claim.
We read your statements against the scheme rules, tariffs and regulations, identify what should have been paid and ask the scheme to correct it.
Services
What we do for medical scheme members
We work on your behalf with your scheme and the regulator. We do not go to court, and we do not give legal or medical advice.
Money wrongly taken from your Medical Savings Account
Hospital, specialist or PMB claims charged to your savings instead of the scheme's risk benefits.
We find the affected claim lines, show why they qualify for risk benefits, and ask the scheme to refund your MSA.
Emergencies and Prescribed Minimum Benefits
A co-payment or shortfall on treatment the law says must be paid in full.
We check whether the event meets the emergency or PMB rules, including the related pathology, radiology and specialist accounts, then press the scheme to pay in full.
Treatment and medicine approvals
A needed treatment, medicine or device was refused or limited.
We build the clinical and legal case with your doctor's motivation and use the scheme's appeal route, then the Council for Medical Schemes.
Statement analysis
You suspect something is wrong but cannot see where.
Send your scheme statements and provider invoices. We tell you what looks wrong and what it might be worth before you decide to go further.
Council for Medical Schemes complaints and appeals
The scheme's own process did not fix it.
We prepare and lodge the complaint, deal with the Council's queries, keep you updated, and help with an appeal if the ruling goes against you.
General information only, not legal, medical or financial advice. Scheme rules and regulations change, and every case turns on its own facts. We cannot guarantee any outcome.