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Tsakani S

1 reviews | Active since Mar 2014

18 Jul 2025, 00:06

Unfair Claim Rejection for Emergency Medical Treatment – Urgent Review Required

I am writing to express my deep dissatisfaction regarding a recent claim related to a traumatic emergency incident. My daughter and I were viciously attacked by two dogs, which left me with severe wounds that required urgent surgical intervention. Given the severity of the situation and the fact that we were far from home, we were both rushed to the nearest hospital’s emergency room for immediate medical care.

To my shock, upon reviewing the claim statement, I discovered that I am being held liable for the full cost of all treatments received at the hospital. This is deeply concerning, especially as I understand that Bankmed’s Emergency Care Benefit—aligned with the Medical Schemes Act—provides for the full cover of emergency treatment regardless of whether the hospital is within the network, as long as it is a medical emergency.

Are patients expected to bleed to death or wait to contract rabies before receiving life-saving care at the nearest available facility? In situations like these, the last thing anyone should worry about is whether the hospital falls within a network. The law and your own benefit documents acknowledge this by providing emergency cover based on urgency, not location.

I urge you to review this claim urgently and rectify the charges incorrectly passed onto me. Kindly also confirm in writing whether this situation does or does not meet the criteria of a medical emergency as defined by Bankmed and the Medical Schemes Act.

I look forward to your prompt response.

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Replies (5)
Bankmed
Bankmed's reply18 Jul 2025, 09:39
Official
Hi Tsakani.

Thank you for bringing this to our attention. We’re truly sorry to hear about what happened and we’re urgently reviewing the matter with the relevant teams. 
TS
Tsakani S's update18 Jul 2025, 15:18
Reviewer Update
Dear Bankmed Team,
I acknowledge receipt of your pre-authorisation letter regarding my recent hospital visit, including the authorisation number and attached treatment codes.
However, I am extremely concerned by the assumptions and decisions communicated in your letter. Based on the content, it appears that the Scheme has concluded that my hospital admission was elective and that I deliberately chose a non-network hospital and practitioner. I must stress that this was not the case.
The hospital visit in question was due to an emergency medical condition, following a traumatic incident where I was attacked by dogs at night, sustaining multiple bite wounds. This required immediate medical attention. In such emergency situations, patients do not have the luxury of comparing hospital networks – the priority is urgent care and survival.
According to Bankmed’s own published guidelines, Prescribed Minimum Benefits (PMBs), especially in the case of emergency medical conditions, should be covered at 100% of the cost, regardless of whether the provider is in the network. However, your letter indicates that my claims will only be covered up to 80% of the Scheme Rate, which directly contradicts this policy.
I have attempted to seek clarity through your call centre, but unfortunately, I was transferred multiple times without receiving a proper explanation. After spending over 30 minutes on the call, I was left without a resolution, which is both frustrating and disappointing.
I respectfully request that you urgently review the classification of my admission, taking into full account the emergency nature of the event. I would also appreciate a direct call from someone who has thoroughly reviewed my case and is able to provide a clear explanation of the decision and how it aligns with Bankmed’s stated emergency PMB policies.
Bankmed
Bankmed's reply18 Jul 2025, 17:13
Official
We note your concerns Tsakani, thank you for the feedback. We will connect with you soon to provide feedback. 

Regards.
Bankmed
Bankmed's reply31 Jul 2025, 18:31
Official
Hi Tsakani, we can confirm that you have been contacted regarding your query.

While your claims have been paid in line with your hospital authorisation, your daughter's claim is subject to a PMB review for out-patient treatment. Thus, we've sent an OHPMB application form for your and the hospital's attention. 

Please let us know should you need further assistance. Regards. 
TS
Tsakani S's update31 Jul 2025, 19:02
Reviewer Update
Thank you for your response. However, I remain dissatisfied and concerned with how my claims are being handled.
Firstly, while I acknowledge that I have been contacted, my concerns have not been adequately addressed. Specifically:
  • For Claim Reference: CPUTKQ (authorisation number ***1), your correspondence clearly states that this would be covered at 100% of the Scheme Rate, and Annexure B1 (page 18) of the Bankmed Essential Plan confirms that I am entitled to one set of crutches every 24 months. Despite this, the claim was rejected and I have now received a hospital invoice (DDE00609), expecting me to pay out-of-pocket for an item that should be covered.
    I have not received a valid explanation for this rejection, and I am still waiting for the promised follow-up.
  • For Claim *** (authorisation number ***9), the claim was also approved in writing, but I noticed it carries a code 6, just like the crutches claim. This raises further confusion about whether it was in fact fully paid or not.
Regarding my daughter’s claim and the PMB review process—thank you for the update. I will completed my part and sent it to the hospital as required. However, this does not resolve the issues above, which pertain directly to my own claims, not my daughter’s. At this stage, it appears that:
  • Claims are being denied or not settled in line with documented authorisations and policy entitlements;
  • There is a lack of transparency in how claim codes and decisions are communicated;
  • I am having to escalate every claim unnecessarily, with limited proactive support.