Letters
Appeal a rejected claim or DSP co-payment letter template
By Naledi Mokoena · 6 min read · Updated 24 June 2026
To appeal a rejected claim or a co-payment, write to your scheme's disputes department, quote the claim number, and state the specific reason the rejection is wrong. Schemes must give you reasons for a rejection, and you have the right to dispute it, then escalate to the Council for Medical Schemes if needed.
Use the template below. Replace every [PLACEHOLDER] and attach the rejection letter, the account and any clinical motivation.
The strongest appeals point to a PMB, a coding error, or an emergency where you could not reach the designated service provider (DSP).
Get the reason in writing first
Before you appeal, ask the scheme for the rejection reason in writing. You cannot argue against a reason you do not have. Common rejection reasons are: benefit exhausted, non-formulary medicine, non-DSP provider, wrong ICD-10 code, late submission, or a treatment the scheme says is not covered. Each has a different counter-argument.
Appeal letter template
[Your full name]
[Membership number]
[Email] | [Cellphone]
[Date]
The Disputes Department
[Scheme name]
RE: Appeal against rejection - claim no. [CLAIM NUMBER], member [MEMBERSHIP NUMBER]
Dear Sir or Madam,
I am appealing the rejection of the claim below.
Claim number: [CLAIM NUMBER]
Date of service: [DATE]
Provider: [PROVIDER AND PRACTICE NUMBER]
Amount: R[AMOUNT]
Rejection reason given: [QUOTE THEIR REASON]
Why I am disputing it:
[CHOOSE THE RELEVANT GROUND]
- This is a prescribed minimum benefit (ICD-10 [CODE]) and must be paid in full.
- The ICD-10 / tariff code on the claim is incorrect; the correct code is [CODE].
- This was an emergency and I could not reasonably use the DSP.
- The medicine is clinically necessary; my doctor's motivation is attached.
What I am asking for: [e.g. the claim to be paid in full / the co-payment reversed].
I attach: the rejection letter, the detailed account, and [CLINICAL MOTIVATION / SUPPORTING DOCS].
Please review and respond in writing with a dispute reference number. If unresolved, I will escalate to the [Council for Medical Schemes](/templates/medical-aid-complaint-letter/).
Yours faithfully,
[Your full name]
[ID number]
Disputing a DSP co-payment
A common dispute is a co-payment for using a non-DSP provider. If you used a non-DSP by choice, the co-payment usually stands. But if it was an emergency, or the DSP was not reasonably available, or you were never told who the DSP was, the scheme should not penalise you. Say clearly which of these applies and attach any proof, such as the emergency admission record.
Escalating to the CMS
If the scheme rejects your appeal or ignores it, escalate to the Council for Medical Schemes. Attach your appeal, the scheme's response, and the claim documents. The CMS reviews whether the scheme followed the Medical Schemes Act and its own rules. PMB and emergency disputes are frequently ruled in the member's favour. Our complaint template covers the CMS step.
Frequently asked questions
Can I appeal a rejected medical aid claim?
Yes. You have the right to the reason for a rejection and the right to dispute it. Write to the scheme's disputes department, quote the claim number, and state why the rejection is wrong. If they refuse, escalate to the Council for Medical Schemes.
How do I dispute a DSP co-payment?
Explain why the co-payment should not apply: it was an emergency, the DSP was not available, or you were never told who the DSP was. Attach proof such as the admission record. If you used a non-DSP purely by choice, the co-payment usually stands.
What are the strongest grounds for an appeal?
A prescribed minimum benefit that was wrongly rejected, a coding error on the claim, or an emergency where you could not use the DSP. These point to clear rules the scheme must follow, which makes them easier to win.
How long do I have to appeal?
Schemes set internal deadlines, often a few months from the rejection. Appeal as soon as you can. If the scheme delays its own response unreasonably, that delay itself is a reason to escalate to the CMS.
Do I need a lawyer to appeal?
No. You can appeal yourself with the template above, and lodging a CMS complaint is free. A broker or your doctor's practice can help with the clinical motivation. Lawyers are only worth it for large or complex disputes.
What if the rejection was a benefit being exhausted?
If your day-to-day or savings benefit is genuinely used up, the rejection may be correct, except for PMBs which must be paid in full regardless. Check whether the claim should have been funded as a PMB rather than from a limited benefit.
