Topmed Medical Scheme Conversion

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SUPPLIER	Topmed Medical Scheme	INDUSTRY	Medical Aid
BRANCH / AREA	Head Office Durban	COUNTRY	South Africa
TIME / DATE	08:45 Thu 22 Sep	PERSON RESPONSIBLE
CUSTOMER	monaheng	View all reports by user	1 0
PROBLEM	Bad service on medical...	Post this report to your Facebook page Post this report to your Twitter page
INCIDENT	Thu 22 Sep
HEADLINE	Payment of claims
I am a Topmed Medical aid scheme client on their network plan. I have been diagnosed with a condition of which my Dr Kolobe of Medicare Family Clinic in Lesotho (A recognised doctor on the network plan) reffered me to a specialist Dr Adamjee (Dermatologist) in Bloemfontein South Africa. The terms of my medical aid scheme are that Topmed will pay for services by a specialist only if their client was referred to that specialist by a Doctor on the network. I went to consult with Dr Adamjee at an initial consultation fee of R400. The Dr Adamjee had some tests conducted at the Ampath Laboratories as part for the diagnosis and treatment. Topmed says they will not pay for the tests amounting to R1952.50 since these test were conducted by a specialist and not their network doctor. What I don't follow is why I would be allowed a referral to a specialist if at the end of the day Topmed will not pay. The amount of money I pay in premiums is enough to cover these treatments. My biggest problem is that I yet have to go for further tests with the Dermatologist as my treatment is not done and I have to pay for myself yet I pay monthly premiums towards Topmed. Add a new Topmed Medical Scheme Report Inappropriate report?
SUPPLIER'S RESPONSE	Topmed Medical Scheme	Time and Date	09:01:59 \| Thu 22 Sep 11
Hello monaheng, Thank you for bringing your enquiry to our attention. I am currently investigating the above and I will get back to you shortly. Kind Regards Lindiwe Mpanza
UPDATED RESPONSE	Topmed Medical Scheme	Time and Date	12:36:27 \| Fri 23 Sep 11
Hello monaheng, We wish to inform you in accordance to the rules and benefits of your chosen option, you, the member has to be referred by a CareCross GP to access your specialist benefit . CareCross do not cover pathology or radiology tests requested by a specialist or medicine prescribed by a specialist. CareCross only cover primary healthcare services and will cover the pathology tests (subject to their formulary) if referred by a CareCross GP. Kind Regards Lindiwe Mpanza
CUSTOMER'S FEEDBACK	monaheng	Time and Date	15:37:12 \| Mon 26 Sep 11
Indifferent: OK. This means I will be paying medical aid scheme and paying doctors fees. No good at having medical cover in this case. I will just have to review my options.