Complaints against medical schemes increased by 24.6% in the 2025/26 financial year, with the Council for Medical Schemes recording 2 413 complaints, up from 1 937 in the previous year.
The increase affected open and restricted medical schemes, according to the CMS’s 2025/26 annual report. Complaints against administrators and health insurance providers also rose, although from much smaller bases.
The report also records progress towards a costed primary healthcare package for Prescribed Minimum Benefits (PMBs) and research into whether medical-scheme administrators should be paid according to outcomes rather than activities.
Complaints rise across the industry
The CMS formally registered 2 455 complaints during 2025/26, compared with 1 962 in 2024/25, an increase of 25.1%.
Medical schemes accounted for 2 413 complaints, or 98.3% of the total. The remaining 42 comprised 23 complaints against health insurance providers and 19 against administrators.
Of the 2 455 complaints registered, 2 323 (94.6%) were assessed as justiciable at the registration stage, meaning they were considered suitable for investigation under the applicable legal framework. The remaining 132 (5.4%) were classified as non-justiciable.
The increase was sustained through most of the year. Complaint registrations were higher year-on-year in 10 of the 12 months, with February 2026 recording the sharpest increase: 104 additional complaints, representing a 140% rise compared with February 2025.
The fourth quarter recorded the highest quarterly volume, with 662 complaints.
Including 456 complaints carried forward from the previous reporting period, the CMS investigated 2 911 complaints during the year. The report clarifies that the carried-forward matters did not constitute a backlog because they remained within the applicable investigation timelines at the start of the financial year.
The Complaints Adjudication sub-division also processed 10 818 emails through its main complaints mailbox. Of these, 8 363 were responded to as enquiries, while 2 455 resulted in formally registered complaints.
The enquiries comprised 7 280 general enquiries, 859 premature complaints or dismissals, and 224 matters outside the CMS’s jurisdiction.
In addition, the sub-division processed approximately 5 800 follow-up queries on pending complaints, 3 593 complaint responses, including supplementary responses, and 147 appeals and related correspondence.
The report does not provide a detailed breakdown of formal medical-scheme complaints by subject. However, separate Customer Care Centre data offer some insight into the questions members and other stakeholders raise.
These included 2 931 queries about the interpretation of the Medical Schemes Act, covering matters such as PMBs, waiting periods, late-joiner penalties and claims-payment rules. A further 2 500 queries concerned scheme benefits, including benefit entitlements, coverage and option-specific benefit structures. The CMS also recorded 4 283 general medical-scheme queries relating to scheme rules, underwriting, membership administration and operational processes.
Open and restricted schemes both see increases
Of the 2 413 complaints against medical schemes, 1 774 were lodged against open schemes and 639 against restricted schemes.
Complaints against open schemes increased by 21.6%, from 1 459 in 2024/25. Those against restricted schemes rose by 33.7%, from 478.
Open schemes accounted for approximately 74% of medical-scheme complaints, with restricted schemes accounting for the remaining 26%. However, the percentage increase was steeper among restricted schemes.
Complaints against other regulated entities also increased.
Health insurance product complaints rose by 35.3%, from 17 to 23. Complaints against administrators increased by 171.4%, from seven to 19.
The CMS linked the increase in administrator complaints to the release of the final Section 59 Investigation Report during the second quarter of 2025/26.
By contrast, complaints against managed-care organisations fell from one in 2024/25 to zero in 2025/26.
No new complaints were registered against brokers during either of the past two financial years.
More than 2 200 medical-scheme complaints resolved
The CMS resolved 2 265 complaints during 2025/26, comprising 2 123 justiciable complaints and 142 non-justiciable complaints.
Medical schemes accounted for 2 223 resolved matters: 1 639 relating to open schemes and 584 to restricted schemes. The remaining resolutions comprised 24 health insurance complaints and 18 administrator complaints.
The report’s ruling outcomes show that complainants received favourable rulings in more than half of the medical-scheme matters in which rulings were issued.
Of 2 086 medical-scheme rulings, 1 152 were in favour of complainants, 847 in favour of the scheme, and 87 were split rulings, with findings in favour of both parties.
The outcomes differed for other regulated entities.
Of 21 health insurance complaints resulting in rulings, nine were decided in favour of complainants, 11 in favour of the entity, and one resulted in a split ruling.
For administrators, three of the 16 rulings favoured complainants, 12 favoured the administrator, and one was split.
A further 142 complaints were classified as non-justiciable at resolution stage: 137 involving medical schemes, three involving health insurance providers, and two involving administrators. The report describes these matters as dismissed due to a lack of merit.
The report does not provide a scheme-by-scheme breakdown of complaints
CMS develops costed primary healthcare PMB package
Beyond complaints, the annual report records progress on the review of PMBs, including the development of a costed draft primary healthcare (PHC) package.
The PMB review is overseen by the Minister of Health, with the National Department of Health (NDoH) leading the work alongside the CMS. The focus is on developing a service-based primary healthcare package for inclusion in the PMBs.
The aim is to establish a package aligned between the public and private healthcare sectors, supporting more equitable access to care and the broader objective of Universal Health Coverage.
During 2025/26, the wider PHC package was refined and prioritised into a core set of nurse- and doctor-led services. The report says this aligns with the draft proposed initial package of health benefits to be considered under National Health Insurance.
A costed draft package has been developed, but its implementation into the PMBs is awaiting the prioritisation and review of the existing PMBs.
The report also refers to the Health Market Inquiry’s recommendation for a standardised base-benefits package that all medical schemes would be required to offer. The proposed package is intended to address the current PMBs’ hospital-centric focus.
The annual report does not specify the total cost of the draft PHC package or give an implementation date.
CMS study questions how administrators should be paid
The annual report also highlights a commissioned study into value-based contracting for third-party medical-scheme administrators. It examined whether administrators’ remuneration could be linked to outcomes rather than activities.
The study responds to concerns raised by the Health Market Inquiry about the relationship between not-for-profit medical schemes and profit-making administrators, including governance influence, costs, ownership of systems and intellectual property.
The research combined a quantitative survey of 43 medical schemes of different sizes and structures with detailed interviews with principal officers and boards of trustees. It examined administration across enrolment, claims processing, regulatory compliance and member communication.
Overall sentiment towards administrators was generally positive, particularly among self-administered schemes and schemes using multiple administrators.
However, smaller and medium-sized closed schemes using third-party administrators identified claims handling, fraud detection and member communication as areas for improvement. These schemes also preferred shorter contract-renewal cycles.
Across the market, provider-relationship management, cost control and pre-authorisation attracted lower satisfaction levels. Information technology and data management were identified as areas requiring sustained attention.
The study supports a shift towards linking administrator remuneration to measurable outcomes, with the aim of aligning incentives more closely with member value and strengthening trustee oversight.
It also proposes that contracts, performance measures and renewal cycles be calibrated to the size and structure of each scheme. System ownership and intellectual-property arrangements would need to be settled contractually to reduce the risk of schemes becoming dependent on incumbent administrators.
These are study findings and recommendations, not a new regulatory requirement. The question is whether administrator contracts should reward the volume of work completed, or place greater weight on how well that work serves schemes and their members.
