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Complaints & Disputes

Hosmed Member Complaints processes

The purpose of this document is to summarise the Complaint process for Hosmed Medical Scheme. This process could be conveyed in the Scheme’s Marketing Materials or Social Media Platforms.
Any beneficiary or any person who is aggrieved with the conduct of Hosmed Medical Scheme can submit a complaint. The Scheme undertakes to assist the Complainant to resolve their complaints in a transparent and accessible manner.
The following steps must be followed to resolve a complaint:

STEP 1: Call the HOSMED call centre and inform the agent of the complaint for further investigation and resolution.
STEP 2: If the complaint is not resolved to the Complainant’s satisfaction after the call to the call centre, a letter of complaint can be emailed to complaints@hosmed.co.za or the Complainant can visit the administrator’s offices from Monday to Friday during 08:00 to 17:00
STEP 3: If the Complainant is dissatisfied with the outcome of the decision, the Complainant can request that the matter gets referred to the Dispute Resolution Committee
STEP 4: If the Complainant is still dissatisfied after the above steps, the matter can be escalated to The Council of Medical Schemes. Complaints can be submitted by letter, fax, email or in person at the CMS offices from Mondays to Fridays during 08:00 to 17:00. For details of the offices, contact numbers, email addresses, please visit: http://www.medicalschemes.com The Council for Medical Schemes governs the medical schemes industry which means it facilitates unresolved complaints for medical schemes.
STEP 5: The Complainant can appeal to the CMS Registrar’s Ruling as per Section 49 of the Act which allows any party who is unhappy with the decision of the Registrar to appeal the decision. This appeal is at no cost to either of the parties. An appeal must be lodged within 30 days of the date of the decision.
STEP 6: If the Complainant is dissatisfied with the Ruling of the CMS Registrar, an appeal can be lodged to the Appeals Board. Either party has 60 days within which to appeal the decision and must submit written arguments or an explanation of the grounds of his or her appeal. The prescribed fee of R2000 is payable for Section 50 Appeals.
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Complaints and Disputes

1.1 Complaints
1.1.1 A Member may lodge a complaint in writing to the Principal Officer.
1.1.2 All complaints received in writing must be responded to, where possible, by the Principal Officer in writing within 30 days of receipt thereof, failing which within a reasonable time.
1.1.3 If the Scheme finds that there is no merit in the complaint, it must notify the complainant in writing of its finding and the reasons for the finding.
1.1.4 If dissatisfied with the finding on the complaint, the complainant may in writing refer the complaint within sixty (60) days of receiving the relevant ruling to the Principal Officer for consideration by a dispute resolution committee of the Scheme.
1.2 Disputes resolution committee
1.2.1 A disputes resolution committee of three (3) members, who may not be Trustees or Employees of the Scheme or employees of the Administrator, shall be appointed by the Board to serve a term of office of three years. At least one of such members shall be a person with legal expertise. The PO and any official of the scheme may attend the meeting of this committee as invitees
1.2.2 The Board may appoint an additional member to the disputes resolution committee in a case where the matter in dispute requires an expert in a specific field in which the appointed members of the disputes resolution committee are not experts in.
1.3 Dispute referred to the disputes resolution committee
1.3.1 Any dispute which may arise between a prospective Member, a Member, former Member or a person claiming on behalf of such Member, and the Scheme or an Employee of the Scheme, or service provider of the Scheme must be referred by the Principal Officer to the disputes resolution committee for adjudication if requested to do so by the Member, prospective Member, former Member or duly authorised representative provided that such dispute has already been handled in terms of the procedure recorded in Rule 28.1, as may be applicable.
1.4 Meeting of disputes resolution committee
1.4.1 On receipt of a request in terms of this Rule, the Principal Officer must convene a meeting of the disputes resolution committee by giving not less than 21 days’ notice in writing to the complainant and all the members of the disputes resolution committee, stating the date, time and venue of the meeting and particulars of the dispute.
1.5 Procedure at meeting
1.5.1 The Board, in conjunction with or on recommendation or advice from the disputes resolution committee may determine the procedure to be followed at a meeting: Provided that
1.5.1.1 the parties to any dispute shall have the right to be heard at the proceedings, either in person or through a representative;
1.5.1.2 the parties may question each other on the evidence presented;
1.5.1.3 the parties may address the disputes resolution committee after all evidence has been heard; and
1.5.1.4 the proceedings of the disputes resolution committee must be minuted.
1.6 The disputes resolution committee shall give a ruling within ten days of the meeting and immediately inform the parties in writing thereof.
1.7 Subject to Rule 28.8 below, the decision of the dispute resolution committee shall be final and binding.
1.8 An aggrieved party has the right to appeal to the Council for Medical Schemes in terms of Chapter 10 of the Act against the decision of the disputes resolution committee. Such an appeal must be in accordance with the provisions of the Act. A copy of the appeal must be forwarded to the Principal Officer.
1.9 The operation of any decision which is the subject of an appeal under Rule28.8 shall be suspended pending the decision of the Council on such an appeal
1.10 Where a Beneficiary’s rights have been infringed under the Consumer Protection Act, 2008 (Act No 68 of 2008) or in the case that he/she seeks redress in respect of any provision which falls solely within the jurisdiction of the Consumer Protection Act, 2008 then in such an instance, the Beneficiary may elect to follow the dispute resolution process contained in these Rules, or otherwise follow the process contained in the Consumer Protection Act, 2008 by directing a complaint as contemplated in Section 69 of that Act.
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How To Guide

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