Complaints & Disputes Process

What kind of disputes may be referred to the Bestmed Dispute Committee?

The Bestmed Disputes Committee is only empowered to hear disputes arising from the membership status of a member which may include, but are not limited to, disputes concerning:

• waiting periods;
• suspensions;
• terminations; and
• contributions.

The Bestmed Disputes Committee may not hear any complaints relating to the conduct of employees of the scheme.

Who may refer a dispute to the Bestmed Dispute Committee?

The following categories of people may lodge disputes with the Bestmed Dispute Committee and shall be referred to thereafter as the “Complainant”:

• A Bestmed member;
• A prospective Bestmed member;
• A former Bestmed member;
• A person claiming on behalf of a Bestmed member;
• An authorised representative of a Bestmed member, prospective member, or former member who cannot act in his/or her own name;
• A member or persons acting in the interest of a group or class of affected persons;
• A person who is acting in the public interest, after having permission of the Bestmed Dispute Committee;
• An association, acting in the interest of its members.

Steps to follow in lodging a complaint/dispute:

STEP 1:

Process to be followed before a dispute can be referred to the Bestmed Dispute Committee:

1. A Complainant must first call the Bestmed call centre on ­­­­­­­­­­­0860 002 378, inform the agent of the dispute and request that the dispute be resolved via the internal escalation process;
2. If the dispute is not resolved to the complainant’s satisfaction, the complainant must write a letter of complaint for the attention of the CEO/Principal Officer via email to disputes@bestmed.co.za. Bestmed will acknowledge receipt of the letter of complaint in writing within forty-eight (48) hours of receiving such a letter. The CEO/Principal Officer will attempt to resolve the matter within thirty (30) days where after the Complainant will receive written feedback regarding the dispute.

STEP 2:

Process to refer a matter to the Bestmed Dispute Committee:

1. If a member is still not satisfied upon the decision of the CEO/Principal Officer, he or she may request that the CEO/Principal Officer refer the matter to the Bestmed Dispute Committee by completing the Bestmed Dispute Referral Form (the form). The member must submit such a request within thirty (30) days of the CEO/Principal Officer’s final decision as noted under Step 1.
2. The CEO/Principal Officer shall confirm receipt of the dispute in writing within five (5) working days of receipt thereof.

What forms must be completed in lodging a dispute?

1. The Complainant must complete the Bestmed Dispute Referral Form (the form) in full, available HERE.
2. The complainant must also provide all supporting documents relating to the matter, such as a medical records;
3. The form and supporting documents must be sent to Bestmed in the following ways:
   • By email: disputes@bestmed.co.za.
   • By hand-delivery & post: Glenfield Office Park, Oberon Avenue, Faerie Glen, Pretoria, Gauteng, 0081, RSA.               

What happens to the form once it has been sent?  

Following receipt of the completed form and subject to any other requirements communicated to the member being satisfied, the CEO/Principal Officer will convene a meeting with the Bestmed Dispute Committee, as soon as reasonably possible. Notice of the meeting shall be given within no less than 21 (twenty-one) days prior notice, stating the date, time and venue of the meeting, and the particulars of the dispute.

Process after the CEO/Principal Officer has sent notice of the meeting to a Complainant and the Bestmed Dispute Committee 

The Chairperson of the Bestmed Dispute Committee will, within seven (7) days of receiving the notice of the meeting and documents, inform the CEO/Principal Officer or Secretariat of the following:

• Who should attend; 
• Whether the Complainant is authorised to refer the dispute to the Committee;
• Outstanding information required by the committee; 
• Any other information that the Committee requires in order to make a decision;
• The Committee may also decide to postpone the meeting if a written request is received timeously from any of the parties;
• If a meeting is postponed, the Secretariat will be responsible for setting a new meeting, in consultation with all the relevant parties;
• If a meeting is postponed, the Committee and the Complainant must be given at least twenty-one (21) days’ notice of the new meeting;
• The Committee will have the sole discretion to decide whether a matter should be postponed or not; with due regard to the reasons for the postponement and the nature of the matter; 
• If a complainant, or another person who was requested to be present at the Committee meeting, does not attend, the Committee will decide if the meeting should continue or be postponed to a later date.

Additional considerations for scheduling disputes.

In consideration of the dispute lodged, the Committee may decide to either adjudicate the matter on papers or request oral evidence. In cases where the Committee decides to adjudicate the matter on the papers, the committee has the authority to request further particulars from the Complainant or from Bestmed.

In arriving at its decision, the Committee will afford both parties the right to be heard in the proceedings.

Legal Representation:

The complainant who wishes to have legal representation must inform the committee within ten (10) days of the sitting that he/she wishes to be represented during the proceedings.

The committee has the right to decide whether to allow such representation or not. Should this be allowed, the complainant making use of the services of a legal representative shall bear the costs of such legal representation.

How will the Bestmed Dispute Committee adjudicate a dispute?

• The Bestmed Dispute Committee, when adjudicating a dispute, shall review all documentation and oral evidence;
• The committee shall then discuss the merits of the dispute and reach consensus;
• If the committee is unable to reach consensus, the committee shall vote on the dispute, with a majority vote decision winning;
• Informing the Complainant of the Bestmed Dispute Committee decision.

The Bestmed Dispute Committee shall, in writing, communicate the decision of the committee to the complainant and to the Bestmed Principal Officer within thirty (30) days after the meeting. 

The decision of the Bestmed Dispute Committee is binding on the Complainant and Bestmed; however, should a Complainant be dissatisfied, the said party may appeal against said decision to the Council for Medical Schemes in terms of Section 48 of the Medical Schemes Act.
The Bestmed Dispute Committee’s decision will be suspended pending the decision of Council for Medical Schemes.

Disputes referred to the CMS:

The Council for Medical Schemes encourages a prospective complainant to first exhaust the complaints mechanisms in place at his/her medical scheme. However, should the Scheme come to knowledge that a Complainant referred a dispute simultaneously to both the Council for Medical Schemes and the Bestmed Dispute Committee, the Scheme shall cease with its internal complaints mechanism and follow the route of resolving the complaint through the Council for Medical Schemes.

Disclaimer

In the event of a conflict between this guide and the Bestmed Rules approved by the Board of Trustees, the Bestmed Rules will prevail and will be applied.          

Annexures        

FORM A: Bestmed Dispute Referral Form.