NL
Natasha L

1 reviews | Active since Jan 2019

11 Jul 2023, 10:26

bridge of contract and suspected *****

I thought I had the best Medical aid ever, until I was booked in the hospital for a procedure they approved only later to be told I'm liable for the rest of the payments. Now my question is when an Authorization letter is send to a member for approval why doesn't it contain an exact amount of what they will pay and why doesn't the best med app state that amount when all it say is " Hospitalization-Inpatient ,accommodation and theatre fees 100% scheme tariff pre authorization required "which was done and approved yet I'm held liable for theatre fees and equipment. what bothers me is that after receiving the news that I'm liable for payment I made a call to bestmed and the lady I spoke to told me that their fees were mentioned on the approval letter and I asked her to re send it to me but to my surprise the letter she claims she's resending looked totally different from the original approval letter that I received which now makes me see that they edited that letter to justify why they are not paying and to me that is *****. I was told on Chats with bestmed that the hospital did not send my clinical records hence the bill is not paid in full so I contacted the hospital and they send the clinical records plus a motivation letter but still the medical aid refused to settle all the outstanding amount. Now I need to understand how a member is liable for theater fees and the instruments used in theater when I was under general anesthesia was I the one using these equipment's on my self. why approve a procedure that you wont pay for and why isn't information provided to me via my app which contains my benefits and why isn't my app showing the remaining balance of this procedure and the amount I utilized like it does on other procedures like internal prosthesis under the "THIS YEARS REMAINING BENEFITS" I ask again, if lapscope, Adhesiolysis and Right tubal Cystectomy does not have its own field on my benefits it means it falls under the scheme inpatient hospitalization and theatre fees which the medical cover 100% following an approval which was granted. I think its time I started looking for other service providers the ***** and the stress is too much now.

0
Replies (4)
Bestmed Medical Scheme
Bestmed Medical Scheme's reply12 Jul 2023, 12:45
Official
Dear Natasha Lebakeng

We received further clinical information and a letter of motivation after an initial authorisation for a day's admission. Upon review, we extended your stay in the hospital. 

A claim has now been reviewed for an overnight stay and is currently awaiting payment. Our payment run occurs twice weekly, every Tuesday and Thursday. As soon as the payment has been processed, we will forward you a claim statement for your records.

I also want to bring to your attention an email we sent on 24/04/2023. This email was addressed to you and the service providers, confirming the limit for Laparoscopic equipment at R5 150.00. Therefore, the content of the email was not altered; a consultant resent it to you as it is. 

Please note that this limit does not reflect on your mobile App as the benefit is subject to approval. 
 
Your well-being, as a valued client of the Scheme, is important to all of us at Bestmed. 

Regards
Nondumiso Letsoalo
NL
Natasha L's update13 Jul 2023, 09:10
Reviewer Update
I understand that but according to the clinical records another procedure was done so I need to understand why is the medical aid sticking on the fees for Lapscope when a separation procedure was done as due to the results of the lapscope.
Bestmed Medical Scheme
Bestmed Medical Scheme's reply14 Jul 2023, 09:09
Official
Dear Natasha Lebakeng

Kindly note that the second procedure, Dilation and Curettage (D&C), is a different type of procedure and is not considered laparoscopic. The limit of R5 150.00 was for laparoscopic equipment, and the claim was more than the allocated limit.

Regards
Nondumiso Letsoalo
NL
Natasha L's update14 Jul 2023, 09:26
Reviewer Update
Nondumiso your still not answering me. A lapscope was done and a separation procedure was done following the results of the lapscope. As you say that the separation procedure is another thing wich the hospital provided clinical records for, unless the medical aid does not cover separation procedures if they do then what needs to be done,does the hospital now have to make a different claim for the separation procedure? I dnt understand because clinical records were provided explaining the procedure and the medical aid could see that 2 procedures were done of which they all fall under my benefits why am I still liable