1 reviews | Active since Mar 2016
Endless Chaos
I have once again had to resort to hellopeter for yet another complaint about this medical aid. I have had four operations for the same issue, the first claim was paid without any issues, while we were underwritten by momentum. Since then I have had endless issues, in my previous complaint they said that they would not pay the anesthetist because he charged non Bankmed rates, they did however pay the surgeon...... This time they paid the anesthetist but not the surgeon, because the surgeon is now not charging Bankmed rates. Does Bankmed have any handle on what they are doing, or do they simply change policy rules during the year, what are we paying the extra "admin fee" for.
At what point can we petition to move away from Bank med or at least request that the Banks remove the Bankmed monopoly and allow to at least go with a dual provider policy where we can elect which provider we would prefer to use.
Hi Charl, we apologise for the delay in responding to your request. We’ve confirmed that your concerns were addressed via email on 16 and 20 November 2017 respectively.
The claims for Dr Lutrin for treatment dates 02 February 2017 and 01 November 2017 were processed correctly in accordance with your chosen plan benefits, the claims were covered at 100 % of the Scheme Rate as Dr Lutrin is not contracted with the Scheme and charged above the Bankmed Scheme Rate. The Scheme encourages members to use providers that participate in our network arrangements so that they may avoid shortfalls on accounts as a result of the provider charging above the scheme rate. Please also refer to your pre-authorisation letter sent to you on the 06 February 2017 and 27 October 2017, which specify that :
1. Claims from your chosen facility will be paid according to your plan at up to 100% of the Scheme Rate for Prescribed Minimum Benefit related benefits as well as non-PMB related
benefits. You will be responsible for any shortfall on the account.
2.Claims from your chosen Healthcare Professional will be paid according to your plan at up to 125% of the Scheme Rate for Prescribed Minimum Benefit related benefits as well as non-PMB related benefits. You will be responsible for any shortfall on the account”
3. You may find a list of Bankmed’s exclusions at www.bankmed.co.za under the Scheme Rules or in your Benefit Guide. There may be some expenses that we do not fund such as for Healthcare Professionals who charge more than the rate covered by your plan or for Healthcare Professionals with whom we do not have an agreement.
Kindly note as well that prescribed minimum benefit (PMB) claims for 2016 were paid in full as an exception. For 2017 PMB claims are funded as per plan type.
The Scheme has an obligation to apply the rules fairly and consistently across the entire membership base and this is why you received consistent responses to your various requests in this regard. We are not insensitive to your plight in dealing with the situation, but hope that we have gained your understanding why the claim was funded in this way. Regards
Hi Charl, we apologise for the delay in responding to your request. We’ve confirmed that your concerns were addressed via email on 16 and 20 November 2017 respectively.
The claims for Dr Lutrin for treatment dates 02 February 2017 and 01 November 2017 were processed correctly in accordance with your chosen plan benefits, the claims were covered at 100 % of the Scheme Rate as Dr Lutrin is not contracted with the Scheme and charged above the Bankmed Scheme Rate. The Scheme encourages members to use providers that participate in our network arrangements so that they may avoid shortfalls on accounts as a result of the provider charging above the scheme rate. Please also refer to your pre-authorisation letter sent to you on the 06 February 2017 and 27 October 2017, which specify that :
1. Claims from your chosen facility will be paid according to your plan at up to 100% of the Scheme Rate for Prescribed Minimum Benefit related benefits as well as non-PMB related
benefits. You will be responsible for any shortfall on the account.
2.Claims from your chosen Healthcare Professional will be paid according to your plan at up to 125% of the Scheme Rate for Prescribed Minimum Benefit related benefits as well as non-PMB related benefits. You will be responsible for any shortfall on the account”
3. You may find a list of Bankmed’s exclusions at www.bankmed.co.za under the Scheme Rules or in your Benefit Guide. There may be some expenses that we do not fund such as for Healthcare Professionals who charge more than the rate covered by your plan or for Healthcare Professionals with whom we do not have an agreement.
Kindly note as well that prescribed minimum benefit (PMB) claims for 2016 were paid in full as an exception. For 2017 PMB claims are funded as per plan type.
The Scheme has an obligation to apply the rules fairly and consistently across the entire membership base and this is why you received consistent responses to your various requests in this regard. We are not insensitive to your plight in dealing with the situation, but hope that we have gained your understanding why the claim was funded in this way. Regards