Any beneficiary or any person who is aggrieved with the conduct of a medical scheme can submit a complaint to the Council for Medical Schemes.
CMS Complaints
Fax: (086) 673 2466
E-mail: complaints@medicalschemes.com
The Fedhealth Independent Ombudsman is here for you
At Fedhealth, we strive to ensure that members understand the decisions taken with regard to their medical aid cover.
Members can sometimes feel that the Scheme is trying to evade its responsibilities in terms of its benefits by declining funding for certain treatments. Clinical decisions made by the Scheme management are based on advice from the Scheme’s medical advisors, and whether the Scheme is obliged to fund the treatment in terms of the benefits of a specific option.
However, it’s also important to us that you have a recourse should you feel the decision does not adequately address your specific circumstances.
As such Mark Hyman has been appointed as an Independent Ombudsman by Fedhealth. Mark is respected within the medical aid industry as a member activist, and Fedhealth looks forward to working with him. Mark’s role will be to assist members who feel that the Scheme is liable to pay for a certain procedure, or didn’t deal fairly with a provider’s request, etc.
- Mark will do this by engaging with the Scheme’s medical advisors and clinical departments to fully understand the issues. Taking into consideration prevailing clinical trends, the requirements of the Medical Schemes Act and the intention of the option benefit design.
- Mark will then deliver a decision as to whether the Scheme should fund a procedure/treatment or if it is not obliged to do so.
- This process will not take away the member’s right to approach the Council for Medical Schemes (CMS) for assistance.
- Any recommendations by the Ombudsman are not binding to either party, but serious consideration should be given to them.
Important: ‘Run of the mill’ complaints, for example, those to do with service delivery, co-payment waiver requests or claims, will not be handled by the Independent Ombudsman.
How to get in touch with Fedhealth’s Independent Ombudsman
Simply email a detailed account of your query to ombudsman@fedhealth.co.za and our senior team will take it further.
Our goal is to facilitate fruitful dialogue and dispute resolution between the Scheme and our members, and we trust that you will make use of this channel should you ever need it.
