1 reviews | Active since Jul 2018
Theatre booking rejected
I have a 3 year old son who is in pain and needs urgent attention, Bankmed refuses to pay his procedure because of the plan that I am in. I find this very unfair because this is an emergency, aren’t there cases were an exception is made or rather let me change the option now so that my 3 year old son can be attended to? This is not something planned its an emergency.
Hi Lorato
We’ve confirmed that this matter has been addressed with you previously, your request for funding in-hospital dental treatment for your dependant from the Hospital Benefit remains declined. Your current plan covers Preventative and Basic Dentistry at 100% of cost, unlimited via the Bankmed Dental Network, subject to the Scheme approved formulary. There are no benefits for advanced Dentistry on the Basic Plan, and in-hospital dental surgery is not covered, except for Prescribed Minimum Benefit (PMB) conditions.
We recognise that the treating doctor is in the best position to make medical decisions regarding the treatment options available. In reaching this decision we have not questioned the diagnosis or the treatment recommended by the treating doctor. As a healthcare funder, we manage carefully planned funding guidelines to ensure the Scheme is able to cover claims now and into the future. Our role is to ensure members of the Scheme enjoy access to quality healthcare in a way that remains affordable and sustainable. Some of the ways we achieve this is in our plan and benefit design, the creation and application of funding policies and clinical protocols which are developed using a rigorous, evidence-based decision-making process.
Plan changes are allowed during Year End Revision which occurs in October each year and the plan change is made effective from January the following year. Members are informed of the Year End Revision through email communication from the Scheme or their employers. When plan changes are requested and the plan type offers more benefits than the previous plan, this is seen as an upgrade and is not allowed during the policy year. This rule is put in place as a risk measure to ensure the overall sustainability of the Scheme and its members.
We are not insensitive to your plight in dealing with the situation, but hope that we have gained your understanding why it is unfortunately not possible to provide the outcome you were hoping for. We can however assure you that the Scheme is acting within the rules and regulation on your specific chosen plan type.
Regards
Bankmed Service Team
Hi Lorato
We’ve confirmed that this matter has been addressed with you previously, your request for funding in-hospital dental treatment for your dependant from the Hospital Benefit remains declined. Your current plan covers Preventative and Basic Dentistry at 100% of cost, unlimited via the Bankmed Dental Network, subject to the Scheme approved formulary. There are no benefits for advanced Dentistry on the Basic Plan, and in-hospital dental surgery is not covered, except for Prescribed Minimum Benefit (PMB) conditions.
We recognise that the treating doctor is in the best position to make medical decisions regarding the treatment options available. In reaching this decision we have not questioned the diagnosis or the treatment recommended by the treating doctor. As a healthcare funder, we manage carefully planned funding guidelines to ensure the Scheme is able to cover claims now and into the future. Our role is to ensure members of the Scheme enjoy access to quality healthcare in a way that remains affordable and sustainable. Some of the ways we achieve this is in our plan and benefit design, the creation and application of funding policies and clinical protocols which are developed using a rigorous, evidence-based decision-making process.
Plan changes are allowed during Year End Revision which occurs in October each year and the plan change is made effective from January the following year. Members are informed of the Year End Revision through email communication from the Scheme or their employers. When plan changes are requested and the plan type offers more benefits than the previous plan, this is seen as an upgrade and is not allowed during the policy year. This rule is put in place as a risk measure to ensure the overall sustainability of the Scheme and its members.
We are not insensitive to your plight in dealing with the situation, but hope that we have gained your understanding why it is unfortunately not possible to provide the outcome you were hoping for. We can however assure you that the Scheme is acting within the rules and regulation on your specific chosen plan type.
Regards
Bankmed Service Team