ET
Eleanor T
1 reviews | Active since Jun 2021
10 Jun 2021, 12:18
Terrible customer service and *****
They are refusing to reimburse my mother for payments she had to make, after they assured her that they would refund her after she made payments to the hospital. Now after hordes of emails and phone calls they just informed her that they would NOT be refunding her. Not a reliable gap cover, use someone else. Claim Number 2021/038848
Helpful (0)
Replies (1)0
Replies (1)
Ambledown's replyOfficial
14 Jun 2021, 22:57Dear Eleanor Theron,
Thank you for the claim review above.
From the reconciliation done, your mother does not have the benefit on the policy for what she was claiming for. Part of the claim was rejected with Reason Code 02 "RC02" Your policy does not include co-payment cover.“Co-Payment” means a stated amount imposed as a co-payment or deductible by a medical scheme. A co-payment or deductible must be indicated in the rules of the medical scheme as approved by the Council for Medical Schemes.” The general exception below was app**** in the assessment of the claim: GENERAL EXCEPTIONS The Company shall not be liable for hospitalisation, bodily injury, sickness or disease directly or indirectly caused by related to or in consequence of
The other part of the claim was rejected with Reason Code 32 "RC32" Paid in full by medical aid scheme.
The Dr charged at 100% of the medical aid scheme rates leaving no "gap" to assess. The main benefit on the product is Gap Cover - A benefit equal to actual cost limited to five (5) times the Medical Scheme Tariff less the higher of the Medical Scheme Tariff or Medical Scheme Option Reimbur*****t Rate for treatment received whilst as an in-patient and/or outpatient (as stated in the Defined Event).
It is our interpretation that the claims were assessed correctly.
I regret that we cannot reverse the decision on the claim but trust that you will find the above explanation to be in order;
The broker on the policy is Talksure Trading. I encourage you to contact the Talksure Client Services Team for clarification regarding the benefits and policy terms and conditions on ***Monday to Friday between 08h00 to 17h00;
The full reply will follow, to your Mom's email account on record.
Should there be anything additional that I can assist with, kindly feel free to reply to the email sent; and
I thank you for your continued support, patience and understanding whilst I was attending to your query.
Yours Sincerely,
Paul Makwea
***
Thank you for the claim review above.
From the reconciliation done, your mother does not have the benefit on the policy for what she was claiming for. Part of the claim was rejected with Reason Code 02 "RC02" Your policy does not include co-payment cover.“Co-Payment” means a stated amount imposed as a co-payment or deductible by a medical scheme. A co-payment or deductible must be indicated in the rules of the medical scheme as approved by the Council for Medical Schemes.” The general exception below was app**** in the assessment of the claim: GENERAL EXCEPTIONS The Company shall not be liable for hospitalisation, bodily injury, sickness or disease directly or indirectly caused by related to or in consequence of
- Co-Payment
The other part of the claim was rejected with Reason Code 32 "RC32" Paid in full by medical aid scheme.
The Dr charged at 100% of the medical aid scheme rates leaving no "gap" to assess. The main benefit on the product is Gap Cover - A benefit equal to actual cost limited to five (5) times the Medical Scheme Tariff less the higher of the Medical Scheme Tariff or Medical Scheme Option Reimbur*****t Rate for treatment received whilst as an in-patient and/or outpatient (as stated in the Defined Event).
It is our interpretation that the claims were assessed correctly.
I regret that we cannot reverse the decision on the claim but trust that you will find the above explanation to be in order;
The broker on the policy is Talksure Trading. I encourage you to contact the Talksure Client Services Team for clarification regarding the benefits and policy terms and conditions on ***Monday to Friday between 08h00 to 17h00;
The full reply will follow, to your Mom's email account on record.
Should there be anything additional that I can assist with, kindly feel free to reply to the email sent; and
I thank you for your continued support, patience and understanding whilst I was attending to your query.
Yours Sincerely,
Paul Makwea
***
Ambledown's reply14 Jun 2021, 22:57
Official
Dear Eleanor Theron,
Thank you for the claim review above.
From the reconciliation done, your mother does not have the benefit on the policy for what she was claiming for. Part of the claim was rejected with Reason Code 02 "RC02" Your policy does not include co-payment cover.“Co-Payment” means a stated amount imposed as a co-payment or deductible by a medical scheme. A co-payment or deductible must be indicated in the rules of the medical scheme as approved by the Council for Medical Schemes.” The general exception below was app**** in the assessment of the claim: GENERAL EXCEPTIONS The Company shall not be liable for hospitalisation, bodily injury, sickness or disease directly or indirectly caused by related to or in consequence of
The other part of the claim was rejected with Reason Code 32 "RC32" Paid in full by medical aid scheme.
The Dr charged at 100% of the medical aid scheme rates leaving no "gap" to assess. The main benefit on the product is Gap Cover - A benefit equal to actual cost limited to five (5) times the Medical Scheme Tariff less the higher of the Medical Scheme Tariff or Medical Scheme Option Reimbur*****t Rate for treatment received whilst as an in-patient and/or outpatient (as stated in the Defined Event).
It is our interpretation that the claims were assessed correctly.
I regret that we cannot reverse the decision on the claim but trust that you will find the above explanation to be in order;
The broker on the policy is Talksure Trading. I encourage you to contact the Talksure Client Services Team for clarification regarding the benefits and policy terms and conditions on ***Monday to Friday between 08h00 to 17h00;
The full reply will follow, to your Mom's email account on record.
Should there be anything additional that I can assist with, kindly feel free to reply to the email sent; and
I thank you for your continued support, patience and understanding whilst I was attending to your query.
Yours Sincerely,
Paul Makwea
***
Thank you for the claim review above.
From the reconciliation done, your mother does not have the benefit on the policy for what she was claiming for. Part of the claim was rejected with Reason Code 02 "RC02" Your policy does not include co-payment cover.“Co-Payment” means a stated amount imposed as a co-payment or deductible by a medical scheme. A co-payment or deductible must be indicated in the rules of the medical scheme as approved by the Council for Medical Schemes.” The general exception below was app**** in the assessment of the claim: GENERAL EXCEPTIONS The Company shall not be liable for hospitalisation, bodily injury, sickness or disease directly or indirectly caused by related to or in consequence of
- Co-Payment
The other part of the claim was rejected with Reason Code 32 "RC32" Paid in full by medical aid scheme.
The Dr charged at 100% of the medical aid scheme rates leaving no "gap" to assess. The main benefit on the product is Gap Cover - A benefit equal to actual cost limited to five (5) times the Medical Scheme Tariff less the higher of the Medical Scheme Tariff or Medical Scheme Option Reimbur*****t Rate for treatment received whilst as an in-patient and/or outpatient (as stated in the Defined Event).
It is our interpretation that the claims were assessed correctly.
I regret that we cannot reverse the decision on the claim but trust that you will find the above explanation to be in order;
The broker on the policy is Talksure Trading. I encourage you to contact the Talksure Client Services Team for clarification regarding the benefits and policy terms and conditions on ***Monday to Friday between 08h00 to 17h00;
The full reply will follow, to your Mom's email account on record.
Should there be anything additional that I can assist with, kindly feel free to reply to the email sent; and
I thank you for your continued support, patience and understanding whilst I was attending to your query.
Yours Sincerely,
Paul Makwea
***