FAQ for Medical insurance disputes and denials

What is a medical insurance dispute?

A medical insurance dispute occurs when there is a disagreement between the medical insurance provider and the policyholder over the payment of a medical claim. The dispute may arise due to various reasons such as the insurer denying coverage, the insurer not paying the full amount of the claim, or the insurer delaying payment.

What are the common reasons for medical insurance denials?

Medical insurance denials can occur due to various reasons, such as:

• The treatment is not covered under the policy
• The policyholder has not met the deductible or co-payment requirements
• The insurer believes that the treatment is not medically necessary
• The insurer believes that the treatment is experimental or investigational
• The policyholder has exceeded the maximum coverage limit

What should I do if my medical insurance claim is denied?

If your medical insurance claim is denied, you have the right to appeal the decision. You should carefully review your policy to understand the reason for the denial and gather any supporting documentation that can help overturn the decision. You should then submit an appeal to your insurance provider, outlining the reasons why you believe the claim should be paid.

Can I take legal action against my medical insurance provider?

In South Africa, you can take legal action against your medical insurance provider if you believe that they have acted unlawfully or unfairly. You should first exhaust all the internal appeal processes provided by the insurance provider before considering legal action. It is advisable to seek legal advice from a qualified attorney who specializes in medical insurance disputes before taking legal action.

How long does it take to resolve a medical insurance dispute?

The timeline for resolving a medical insurance dispute can vary depending on the complexity of the case and the appeal processes involved. Generally, the insurer has 30 days to respond to an appeal. If the dispute is not resolved through the internal appeal process, it may be referred to the Council for Medical Schemes or the Ombudsman for Long-term Insurance, which can take several months to reach a final decision. If the dispute goes to court, it can take several years to resolve.