Medical Aid Claim Rejected — How to Appeal in South Africa
A medical aid scheme must fund prescribed minimum benefits in full. If your claim is rejected, you have the right to appeal internally and to the Council for Medical Schemes — free of charge.
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Direct Answer
The Medical Schemes Act requires every registered medical scheme to cover Prescribed Minimum Benefits (PMBs) at cost — regardless of your benefit option. If your claim for a PMB condition is rejected, you can appeal to the scheme internally within 30 days, then escalate to the Council for Medical Schemes at no cost.
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“A medical scheme must pay in full for the diagnosis, treatment and care costs of any emergency medical condition and the PMB conditions listed in Annexure A.”
Medical Schemes Act 131 of 1998
Section 47
“A medical scheme must have an internal complaint resolution mechanism and must inform members of their right to escalate to the Council for Medical Schemes.”
What to Do
Step-by-Step Guide
1Get the rejection in writing with full reasons. Schemes must provide written reasons for any rejection.
2Check if your condition is a PMB. The full PMB list is in Annexure A of the Medical Schemes Act regulations. If it is a PMB, the scheme must cover it at cost — no benefit limits, no co-payments for the PMB component.
3Lodge an internal appeal in writing within 30 days of the rejection. Cite the specific PMB condition and the section of the Act.
4If the internal appeal fails, escalate to the Council for Medical Schemes (CMS): 012 431 0500 or complaints@medicalschemes.com. This is free and the CMS can order the scheme to pay.
5Gather supporting documents: treating doctor's motivation letter, diagnosis codes (ICD-10), treatment plan, and invoices. A strong clinical motivation is key.
What to Say
Exact Words to Use
“"My condition [condition name] is a Prescribed Minimum Benefit under Annexure A of the Medical Schemes Act. Section 29(1) requires you to fund this in full at cost. I am appealing your rejection in writing and will escalate to the Council for Medical Schemes if this is not resolved within 10 business days."”
Tone: In writing to the medical scheme
Now practise saying it. The Advocate has a scenario that walks you through exactly this situation — phrase by phrase, with audio playback and a practice drill. Free to try.
PMBs are 270 conditions (including 25 chronic conditions and emergency medical conditions) that all registered medical schemes must cover in full, at cost, regardless of your benefit option. They include conditions like diabetes, hypertension, asthma, HIV, and all emergency care.
Can the scheme impose a co-payment on a PMB claim?
Only if you were treated at a non-designated service provider without a valid reason (e.g., emergency). If you used the scheme's network providers for a PMB condition, no co-payment applies. A scheme imposing co-payments on PMB claims is in breach of the Act.
Get Help Now
Resources & Helplines
Council for Medical Schemes
012 431 0500
Free appeals and complaints against medical schemes.
Knowing the law is step one. The Advocate has scenarios on Health — practise the exact words to use, with audio, law references, and Scripture. Free to start.