Bestmed - decline of medical treatment and PMB's excluded

Bestmed Medical Aid no. ********** 22 – refers – member : Andre Pretorius ( ********** / ********** ).

I joined the scheme on 1-July-2018 and had to undergo the 3 months waiting period ending 30-September-2018. On 8-November-2018 I have injured my back whilst visiting my 89 year old grandmother in hospital just by lifting her up a bit higher in her hospital bed. There were NO signs of any injury at that time , but 2 days later , on Saturday morning 10-November-2018 , I could not get out of bed. I couldn’t straighten my back and when I got onto my legs , they caved in underneath me and were semi-paralyzed. a While later I realized that this is the only way I could have injured my back.

I started treating myself with anti-inflammatories and pain medication on hand , but after a month there were still not improvement , in fact , it worsened. On 10-December-2018 I decided to consult my GP for the first time to ask for aid with different medicines in the attempt to give me relief. Needless to say that from here it went downhill and got more worse. I was sent for CT-scans on 22-January-2019 where it was discovered that 3 of my lumber discs were injured and were in a severe process of degeneration. I was booked to see a Neurosurgeon on 12-February-2019 which I did – he referred and booked me for a Fluoroscopy of by back on 25-February-2019.

On 25-February-2019 , when arriving at hospital for the procedure , I was told that I have to pay the full amount upfront due to the fact that my condition was declined and so EXCLUDED during my original application for membership (1-July-2018) , at which time I had NO problems with my back ever. On my original application to Bestmed in June-2018 I declared that I had a neurostimulator implanted in my back for severe neuropathy in both of my legs , including a letter from the surgeon to state the latter. Bestmed went and EXCLUDED my back for a year - the neurostimulator has NOTHING / NO REALTION to my back at all but only to my legs. I NEVER in my life had a back problem up to now , it arose 4 months ago when I accidentally and unknowingly injured my back as mentioned above.

I had to cancel everything that was arranged for the 25th and told them to “stuff” the case , straight into their faces , that’s how upset I was ! Bestmed REFUSED me treatment for an injury which arose accidentally and could have happened to anyone , like walking down the steps , falling , fracturing and arm or a leg or even a hip.

I am in terrible pain currently and I had to go back to my GP on 25-February-2019 where he said to me that the only option he now has is to give me Morphine tablets until such time that I can get professional medical help / - treatment so I can at least get some relief. I also paid CASH for these tablets !

I contacted a friend who is the head underwriter of one of the largest medical aids schemes and insurance companies in the country. He informed me that it was ******* to exclude my back for a year , even the fact that I had undergone the 3 months initial waiting period (1-July-2018 to 30-September-2018) , exclusion is NOT allowed. My current back problem has NOTHING to do with the neurostimulator that was implanted into my side and my back on 5-March-2012. I have to state that my Hypertension (classified as a PMB in terms of the CMS) has ALSO been excluded by the medical aid for a year and I have to take BP medication twice daily , as I am doing for the +- past 15 years (classified as chronic). My friend also informed me that this EXCLUSION is against the law and should have been included and paid for from day one , the cost of my BP medication amounts to about R180 per month. I have been paying for this out of my own pocket all along , although declared as a chronic condition on my original scheme application form.

Bestmed :- 1). Why is my back excluded from the medical aid although I NEVER had any back problems in my life before , and 2). My Hypertension is a defined and prescribed PMB – why is this EXCLUDED for a year ?

I demand an investigation and PROPER answers from Bestmed why I am in the position I am currently taking into account the explanations above. I also intend laying complaints at the Council for Medical Schemes as well as the Consumer Council , and might even consider legal action should I not get proper and adequate answers and action from them !