Complaints and Disputes
According to the Scheme rules, members may lodge a complaint with the Scheme in any of the following ways:
contact: 0861 000 300;
email: firstname.lastname@example.org; or
write: to Moto Health Care at PO Box 2338, Durban 4000.
When you lodge a complaint, the Scheme will acknowledge receipt within 2 working days. There are, however, complaints that need clinical input and investigation and these claims would take longer to resolve. In these cases the Scheme will respond within 30 days.
How to file a complaint via the internal process
- Call the Customer Service Centre on 0861 000 300 and speak to a service consultant. The member must always obtain a reference number when making a complaint. This reference number is linked to the case (complaint) in the system.
- If the complaint is not resolved, the member can send the query to the consultant's team leader and/or a customer relationship manager.
- If the matter is still not resolved, the member may escalate the query to the Scheme's Fund Manager and finally the Principal Officer. At this level, a request may be referred to the scheme's medical advisory panel for their consideration.
- If the member is still not satisfied, the member can send a letter of appeal to the Scheme or its Medical Advisory Committee. This can be in the form of either a formal letter or an email – with information on the declined decision and further motivation or new clinical evidence.
- If the decision made by the Medical Advisory Committee is not acceptable, the member can ask the Scheme's Board of Trustees to review the decision.
External complaint process
- Once the member has exhausted the internal complaint process, the member may declare a dispute. On written request from the member wherein the full particulars of the complaint is detailed, including proof of all prior interaction with the Scheme and its contracted service providers, where applicable, the Principal Officer will call a meeting of the Dispute Committee to decide on the matter.
- If the member is not satisfied with the ruling of the Dispute Committee, the member may lodge an appeal with the Council for Medical Schemes.
The dispute process
Please make use of all internal procedures available to you to lodge a complaint before appealing an outcome.
The appeals process that must be followed, should you not be satisfied with the outcome of your complaint, is:
1. Request in writing that your complaint be escalated to the Disputes Committee.
2. If you are still not satisfied with the outcome of the Dispute Committee’s ruling, you can lodge a complaint with the Registrar for Medical Schemes.