Dispute Resolution

 DISPUTE RESOLUTION PROCEDURE

Click here to access the Dispute Resolution form.

a) GEMS Rule 30 on complaints and disputes makes provision for the resolution of disputes that may arise between, on one hand,

i) a Member;
ii) a prospective Member;
iii) a former Member;
iv) a person claiming on behalf of a Member;
v) An authorized person acting on behalf of the person referred to in (a) (i), (a) (ii) and (a) (iii) above;
vi) An authorized person acting on behalf of the person referred to in (a) (i), (a) (ii) and (a) (iii) above who cannot act in his or her own name;
vii) An authorized person acting as a member of, or in the interest of, a group or class of affected persons;
viii) An authorized person acting in the public interest with leave of the Dispute Committee; and
ix) An association acting in the interest of its members.
("the Complainant") and the Scheme or any of the officers of the Scheme.

b) A Complainant may refer a dispute for adjudication only after a complaint has been handled according to the procedure described in GEMS Rule 30.1 to 30.4.  In short, the Rules stipulate that a Complainant must log his/her complaint with the Scheme's call centre.  Where a complaint against the Scheme cannot be resolved by the call centre, the Complainant may refer a complaint in writing to the Scheme for the attention of the Principal Officer.  Upon the Scheme's receipt of a complaint, it will acknowledge receipt in writing within 24 hours of such receipt and endeavour to process the complaint within 30 days of receipt or as soon as reasonably practicable thereafter. The Complainant will be notified in writing of the Scheme's findings and if still dissatisfied, may, in writing and within 60 days of the date of receipt of such notification, refer the complaint to the Principal Officer for consideration by the Dispute Committee.

2) Procedure

a) Lodging of Disputes

i) A Complainant who wishes to refer a dispute to the Dispute Committee for adjudication must obtain a copy of the Scheme's official dispute referral form attached at appendix A hereto (the "Form").

ii) The completed Form may be delivered, posted, faxed or e-mailed to the Scheme's contracted Administrator.

iii) A completed Form must contain the following information and meet the following requirements before further processing will take place:

• A copy of the letter from the Principal Officer whereby the Complainant was informed of the Scheme's findings and the reasons therefor, must be attached to the Form; and
• If a dispute is lodged by a prospective, current or former GEMS member, the Form must be signed by that member; or, if a dispute is lodged by a representative of any such GEMS member, the Form must be signed by that GEMS member and his/her representative and must include a written authorization by the GEMS member to his/her representative to conduct the particular dispute on that GEMS member's behalf; or
• If a dispute is lodged by a member of a group or class of affected persons as contemplated in paragraph 1)a)vii), the Form must be signed by that member; however, if the dispute is lodged by a person acting in the interest of a group or class of affected persons as contemplated in paragraph 1)a)vii), the Form must be signed by the person so acting; or
• If a dispute is lodged by a person purporting to act in the public interest as contemplated in paragraph 1)a)viii), the Form must be signed by that person; or
• If a dispute is lodged by a representative of an association, acting in the interest of its members as contemplated in paragraph 1)a)ix), the Form must be signed by such representative, the head of that association and must include a written authorization by the head of the association to conduct the particular dispute on behalf of that association.

iv) In respect of the requirements specified in paragraph 2)a)iii) above, if a dispute is lodged by a Complainant who purports to act as the representative of a party, and it is not possible for the Complainant to obtain the signature of such party or any of the Required Documentation due to whatever reason, the Complainant must sign the Form and include those of the required signatures and Required Documentation which he/she was able to obtain and a duly sworn affidavit stating the reasons for his/her inability to obtain the signature of such party and the steps taken to obtain such signature or any of the Required Documentation ("the Affidavit").

v) The Scheme's contracted Administrator will acknowledge receipt of the Form to the Complainant and provide the Principal Officer with a copy of the Form and the acknowledgement of receipt within 48 hours of receiving the Form.

b) Dispute Resolution Proceedings

i) After receipt of the Form and the acknowledgement of receipt from the Administrator, the Principal Officer will, as soon as reasonably practicable following his/her receipt of all the documentation relating to the matter in dispute, convene a meeting of the Dispute Committee by giving not less than 21 days notice in writing to the Complainant and all the members of the Dispute Committee, stating the date, time and venue of the meeting and the particulars of the dispute, including all the documentation relating to the matter in dispute.

ii) The Chairperson of the Dispute Committee will,  within 7days from the date of his/her receipt of all the documentation relating to the matter in dispute, communicate to the Principal Officer in writing on whether:

(1) expert evidence / advice (not available among the members of the committee) will be required at the meeting;
(2) officers or agents of the Scheme shall be required to give evidence at the proceedings;
(3) the Committee requires the Complainant to be present at the meeting to give evidence;
(4) (if a dispute is lodged by a person purporting to act in the public interest as contemplated in paragraph 1)a)viii), and only once it has been determined by the Chairperson by way of round-robin resolution, based on the facts stated in the Form of such person, that the Dispute Committee members are satisfied that such person may be regarded to be acting in the public interest) the Dispute Committee has given leave for such person's dispute to be heard by the Dispute Committee. Should the Dispute Committee resolve not to grant such person's request to act in that capacity, the Chairperson will relay the decision and the reasons therefor in writing to the Principal Officer, who will subsequently inform such person in writing within 24 hours of his/her receipt of such written confirmation from the Chairperson; and
(5) (if a dispute is lodged by a Complainant who purports to act as the representative of a party, and the Complainant has signed a Form and included an Affidavit, and only once it has been determined by the Chairperson by way of round-robin resolution, based on the facts stated in the Form and the Affidavit, that the Dispute Committee members are satisfied that such Complainant, has, for good reason, not been able to obtain the signature of such party or any of the Required Documentation for whatever reason) the Dispute Committee is reasonably satisfied that such Complainant has sufficient authority to represent such party. Should the Dispute Committee resolve that it is not reasonably satisfied that such representative has sufficient authority to represent such party, the Chairperson will confirm the decision and the reasons therefor in writing to the Principal Officer, who will subsequently inform the Complainant in writing within 24 hours of his/her receipt of such written confirmation from the Chairperson.

iii) The meeting pack, including the final agenda, will be distributed to the members of the Committee after receiving the information referred to in paragraph 2)b)iii) above.

iv) Meetings of the Dispute Committee may be held at the registered offices of the Scheme at the Hillcrest Office Park, corner of Lynnwood and Dyer Road, Pretoria, or at any other suitable venue at the Scheme's sole discretion.

v) The Chairperson of the Dispute Committee may decide to postpone a scheduled meeting provided that:

(1)  a designated officer of the Scheme or the Complainant provides the Committee with sufficient written motivation; and
(2)  the request for postponement is received at least 7 days prior to the scheduled meeting; unless the Chairperson finds that the case is an emergency to be heard urgently.

vi) If a meeting is postponed, the Principal Officer shall set a new meeting date by giving not less than 21 days notice in writing to the Complainant and the members of the Committee of the date and time of the meeting.

vii) If a Complainant who was requested to be present at the hearing, or an official or agent of the Scheme designated to give evidence at a meeting of the Dispute Committee, fails to attend or be represented at the meeting, the Committee may:

(1) Continue with the proceedings in the absence of the Complainant or Scheme respondent; or
(2) Adjourn the proceedings and request the Principal Officer to set a new meeting date in accordance with paragraph 2)b)vi) above. 

c) Emergency Procedure

i) The Principal Officer shall notify the Chairperson if a dispute is referred to the Committee on an emergency basis.

ii) The Principal Officer will convene a meeting as soon as reasonably practicable in consultation with the Chairperson and the Committee members if a case is found to be an emergency on the basis that failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy.

d) Communication

i) The Chairperson of the Dispute Committee will communicate the decision of the Committee in writing to the Complainant and the Principal Officer within 7 days of the date of the Dispute Committee meeting.

e) Binding nature of Dispute Committee decisions

(i) In accordance with the registered Rules of GEMS, any decision of the Dispute Committee shall be final and binding on the Scheme and the other parties to the dispute.

(ii) A Complainant who is aggrieved by a decision relating to the settlement of a dispute may appeal to the Council for Medical Schemes against the decision of the Dispute Committee in accordance with Section 48 of the Medical Schemes Act, 1998.

(iii) Such an appeal must be in the form of an affidavit directed to the Council for Medical Schemes and must be furnished to the Registrar of Medical Schemes not later than 3 months (or such further period as the Council may, for good cause shown, allow) after the date on which the decision concerned was made by the Dispute Committee.

(iv) The operation of any decision which is the subject of an appeal to the Council for Medical Schemes, will be suspended pending the decision of the Council on such an appeal.