AMBLEDOWN GAP COVER - STALLING TACTICS

My past experiences with Ambledown have been pleasant and prompt. However there is a new "tactic" that has reared its head in the past few claims I have had with them......"We have assessed your claim and have found that the shortfall should have been covered by the Medical Scheme. Your claim is now with a specialist who is liaising with the medical scheme administrator." I firmly believe that this is a new stalling tactic! Momentum Health impose a co-payment of R1500 on ANY/ALL hospital admissions and a Co-Payment on MRI scans IN or OUT of Hospital - clear plain and simple, we have to pay the Co-Payment and claim it back from GAP Cover. Momentum will NOT pay for the Co-Payment whether it is a PMB or not. I do not understand why Ambledown don't/can't/won't comprehend this concept? After numerous frustrating calls to their help desk, I feel sorry for the poor guys answering the phone, it's not their fault and ask to speak to an assessor ...WELL that's impossible as they are ALWAYS busy and don't call back.

My policy Number is AMBL*** and have 2 outstanding claims for Co-Payments, (One is for admission through Trauma for my wife - Paid the R1500 to Westville Hospital; the other is for in hospital MRI R2500 for myself) never mind the doctors & anesthetist shortfalls that are delayed because the brakes get app**** from the onset by stymieing the claim by referring it back to Momentum as a PMB! They claim that for my wife's trauma admission the ICD10 Code on the hospital bill T39.3 is "Malignant neoplasm, breast, unspecified" on the Hospital ICD code it is "Poisoning, other non steroidial" Who is right who is wrong?

Haw can a ICD 10 code be misinterpreted. Why would I admit a swollen allergic reaction very sick wife through trauma who was hospitalized for 3 days on cortisone and anti allergy medication - and explained this on the claim form for cancer?

I ask you with tears in my brown eyes?

I am at my wits end PLEASE ASSIST!

Greg Robertson.