Benefits & claims
How to claim from your medical aid
By Naledi Mokoena · 5 min read · Updated 24 June 2026
Most medical aid claims are submitted directly by the hospital, doctor or pharmacy to your scheme, so you rarely lift a finger. When you do pay upfront, you submit the account and proof of payment yourself and the scheme refunds the covered portion to your bank account.
Knowing how claims work, and the deadlines, stops you losing money on care you were entitled to. This guide covers the two ways claims happen, pre-authorisation, and what to do when a claim is rejected.
Direct claims vs paying upfront
There are two routes:
- Direct claim. The provider sends the account straight to your scheme and is paid directly. You pay only any co-payment or shortfall. This is the most common route for hospitals and most doctors.
- Pay and claim back. You pay the provider, then submit the account and proof of payment to the scheme for a refund of the covered portion into your bank account.
How to submit a claim
To claim back what you paid:
- Get a detailed account (not just a till slip) showing the provider, date, tariff codes and amount.
- Submit it via the scheme app, member portal or email, with proof of payment and your membership number.
- Keep a copy and note the submission date.
The scheme pays the covered amount to your nominated bank account, usually within a claims cycle.
Pre-authorisation for hospital
For any planned hospital admission or certain procedures, you must get pre-authorisation before the date. The scheme gives you an authorisation number and tells you any co-payment. Skipping pre-authorisation can lead to a penalty or a rejected claim. In an emergency, get authorisation as soon as reasonably possible afterwards.
Claim deadlines
Schemes set a deadline for submitting claims, commonly up to four months from the date of service. Miss it and the claim can be rejected as stale, even if it was valid. Submit promptly and keep proof. If a claim is rejected for being late but you submitted on time, your dated submission is your evidence.
If a claim is rejected
First check the rejection reason on your claims statement - it may be a missing code, a benefit limit, or a non-DSP issue you can fix. If you believe a valid claim (especially a PMB) was wrongly rejected, dispute it in writing with the scheme. If unresolved, complain to the Council for Medical Schemes at medicalschemes.co.za.
Frequently asked questions
How do I claim from my medical aid?
Usually the provider claims directly and is paid by your scheme. If you paid upfront, submit the detailed account and proof of payment via the app, portal or email, and the scheme refunds the covered portion.
How long do I have to submit a claim?
Schemes commonly allow up to four months from the date of service, but check your scheme rules. Submit promptly, because a late claim can be rejected as stale even if it was valid.
What is pre-authorisation?
Pre-authorisation is approval you get from the scheme before a planned hospital admission or certain procedures. The scheme issues an authorisation number and tells you any co-payment. Skipping it can lead to a penalty.
What do I do if my claim is rejected?
Check the rejection reason on your statement first, since it may be fixable. If a valid claim was wrongly rejected, dispute it in writing, and if unresolved complain to the CMS at medicalschemes.co.za.
Will the scheme pay the provider or me?
On a direct claim, the scheme pays the provider and you pay only any shortfall. If you paid upfront, the scheme refunds the covered amount to your nominated bank account.
Do I need to claim for hospital stays?
Hospitals usually claim directly, but you must arrange pre-authorisation beforehand. You are responsible for getting the authorisation number, not for submitting the hospital's claim.
