Letters
Medical aid complaint letter and CMS escalation template
By Naledi Mokoena · 6 min read · Updated 24 June 2026
To complain about your medical aid, first lodge a written complaint with the scheme's disputes or complaints department and give them a reference number to work with. If they do not resolve it within a reasonable time, you can escalate free of charge to the Council for Medical Schemes (CMS), the statutory regulator.
Use the two templates below: one to the scheme, one to escalate to the CMS. Fill in every [PLACEHOLDER] and attach copies of claims, letters and reference numbers.
Keep your tone factual. State what happened, what rule or benefit you rely on, and exactly what outcome you want.
Step 1: complain to the scheme first
The CMS expects you to give the scheme a fair chance to fix the problem before they step in. Lodge your complaint in writing with the scheme's complaints, disputes or client services department. Quote your membership number and any claim or authorisation numbers. Ask for a written response with a reference number and a deadline.
Template: complaint to the scheme
[Your full name]
[Membership number]
[Email] | [Cellphone]
[Date]
The Complaints Department
[Scheme name]
RE: Formal complaint - membership no. [MEMBERSHIP NUMBER]
Dear Sir or Madam,
I am lodging a formal complaint about the following:
What happened: [DESCRIBE THE ISSUE - e.g. claim number 12345 for R[AMOUNT] was rejected on [DATE]].
Why I believe this is wrong: [STATE THE BENEFIT, RULE OR PMB YOU RELY ON].
What I want: [THE OUTCOME - e.g. the claim to be paid in full / the co-payment reversed / a written explanation].
I attach: [LIST DOCUMENTS - claim, rejection letter, account, scheme rule].
Please provide a written response and a complaint reference number within [e.g. 30 days]. If this is not resolved, I will escalate to the Council for Medical Schemes.
Yours faithfully,
[Your full name]
[ID number]
Step 2: escalate to the CMS
If the scheme does not respond or the response is unfair, you can lodge a complaint with the Council for Medical Schemes. The CMS handles complaints against registered medical schemes and administrators. There is no charge. You will need the scheme's reference number and copies of your correspondence so they can see you tried to resolve it first.
Template: escalation to the CMS
[Your full name]
[ID number]
[Email] | [Cellphone]
[Date]
The Complaints Unit
Council for Medical Schemes
RE: Complaint against [SCHEME NAME] - member [MEMBERSHIP NUMBER]
Dear Sir or Madam,
I wish to lodge a complaint against [SCHEME NAME] under the Medical Schemes Act.
Summary: [ONE OR TWO SENTENCES ON THE ISSUE].
What the scheme decided: [THEIR DECISION AND DATE, plus their reference number].
Why I am disputing it: [YOUR REASON, referring to PMBs or scheme rules if relevant].
What I am asking the CMS to do: [e.g. review the rejection and direct the scheme to pay].
I attach my complaint to the scheme, their response, and the relevant claims and statements.
Yours faithfully,
[Your full name]
What the CMS can and cannot do
The CMS can investigate, ask the scheme to explain, and rule on whether the scheme followed the Medical Schemes Act and its own rules - including prescribed minimum benefits (PMBs). It cannot force a scheme to pay for something that is simply not a registered benefit and not a PMB. Frame your complaint around a rule, a benefit, or a PMB the scheme should have honoured.
Frequently asked questions
Who is the medical aid ombudsman in South Africa?
There is no separate medical aid ombudsman. The Council for Medical Schemes (CMS) is the statutory regulator that handles complaints against registered medical schemes. You complain to your scheme first, then escalate to the CMS if it is not resolved.
How long does the scheme have to respond to my complaint?
There is no single fixed deadline, but it is reasonable to ask for a written response within 30 days. If they miss that or the answer is unfair, escalate to the CMS and attach your original complaint and any reply.
Does it cost anything to complain to the CMS?
No. Lodging a complaint with the Council for Medical Schemes is free. You do not need a lawyer or a broker to do it, though you can ask one to help if your case is complex.
What should I attach to my complaint?
Attach the claim or account, the scheme's rejection or decision letter, your membership number, and your written complaint to the scheme plus their reply. The more clearly you show the timeline, the easier it is to resolve.
Can I complain about a rejected PMB claim?
Yes, and these are among the strongest complaints. If your condition is a prescribed minimum benefit and the scheme refused to cover it through a designated service provider, the CMS can direct the scheme to pay. See our PMB application template for how to frame it.
Should I keep paying contributions while I dispute?
Yes. Keep your membership in good standing while the dispute runs. Stopping payment can cause your cover to lapse, which weakens your position and can leave you uninsured during the dispute.
