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Clinical Dispute Resolution

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Clinical Dispute Resolution Process
This process is for hospital, medicine & disease authorisation disputes
POLMED makes provision for members, healthcare providers and third parties to lodge complaints or enter into disputes should they disagree with a particular funding outcome.Here are the steps to follow when lodging an appeal or when entering into a dispute.

Written request:
This is a formal letter that is sent either via post or as an e-mail attachment, clearly indicating the purpose of the communication. A written appeal must be legible and contain all the relevant membership information, including personal information, a membership number and dependant codes, as well as Scheme option. The decision against which the appeal is being made must be clearly stated and all the supporting documents must be attached. The appellant must send the written request to the relevant department within 30 days of receipt of the outcome or decision:

The appellant must always address the appeal to the relevant department; for example the POLMED Chronic Medicine Management programme for disputes related to medicine.

The department will forward your appeal to the Clinical Committee. While your appeal is being processed, you may get a letter asking you to provide more information or documentation. If you send this information to us, we may be able to informally resolve your case fairly quickly.

For urgent matters, feedback on the resolution of the dispute is provided in writing within five working days after receiving all the necessary information.

Non-urgent matters are discussed at the Clinical Committee review meeting, which sits once a month. Feedback is provided in writing within five working days after the meeting.

Should you still not be satisfied with the outcome of the above processes, you may lodge a complaint with the Council for Medical Schemes by using one of the following channels:

  • Post: Council for Medical Schemes, Private Bag X34, Hatfield 0028
  • Phone: 0861 123 267 (share call from a Telkom landline) or
    012 431 0500
  • Fax: 012 431 0608 or 012 430 7644
  • E-mail: complaints@medicalschemes.com