19 Sep

Member-centric call centres a must for medical schemes

call centres


Complaints and queries need a personal response

People use medical aid schemes to assist them with paying their medical bills. Let’s be honest – private healthcare can be seen as a massive grudge purchase, due to the fact that members pay their necessary monthly contributions, but rarely encounter the benefits as a result of a large accident, illness or disease.

Generally speaking, members are happy when their claims are settled in line with their expectations and the only time they contact their scheme is to obtain a tax certificate or to update personal details.

From time to time, however, members find themselves in the dire situation where bills are not paid – either partially or in full – and then they complain. Loudly and publicly. Complaints fly around on social media, some make their way to Hellopeter and some are formally lodged with the Council for Medical Schemes (CMS).

According to the latest published annual report from the CMS, only about 28% of the complaints received were found to be “valid”.


Medical aid related complaints, whether members are on a hospital plans or comprehensive medical aid plans can, generally speaking, be channeled into two main categories; namely benefits related complaints and service related complaints.

Trying to resolve benefit related complaints is probably one of the most difficult areas in striving for member satisfaction in any medical scheme call centre environment, as the member, in all likelihood, was never familiar with his/her exact benefits and the scheme rules to start with.

The “contract” between the scheme and the member is the rules of the scheme that are binding on all members. Claims that are short paid or rejected are assessed according to the benefits (or limitations) set out in the rules and are not based on the subjective assessment of a claims assessor.

Neither wild/slanderous accusations when claims are not paid, nor the most fantastic call centre staff, can change the outcome of these types of complaints. The responsibility of understanding membership terms and conditions will always remain that of the member. It cannot be shifted to the medical scheme or another third party.

Service related complaints, however, are driven by predominantly service expectation, perceived quality and perceived value. In this instance, the paramount importance of call centres can never be underestimated. Competent staff should be taught that unsatisfactory service cannot be replaced or repaired and that, irrespective of whether members’ complaints are valid or not, members’ biggest needs are to be heard, to be understood, to be given timeous feedback and to rely on accurate and consistent feedback.


Whilst all members are supposed to be familiar with their scheme rules, the reality is that they aren’t. Most members, however clever or intellectual they may be, don’t know (and they don’t care) about scheme rules, solvency ratios, the Act, etc.

Good service from call centres is about how they make their members feel during that call. Even though members’ claims/demands may not be valid, it is an unforgivable sin to ignore, mistreat or belittle members. The issue for many members is often not the fact that they don’t have a benefit, but in the way they are treated when questioning a benefit that they don’t understand.

Call centres should continuously strive to maintain the human touch in all the elements of their member interaction. Members don’t want to talk to machines and they don’t want to be ignored. They want to be treated with dignity and respect.


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