FORMAL DISPUTE

I am formally disputing the way my recent optical claim was processed by Bonitas under my BonFit Select plan.

The BonFit Select benefit information shows an optical benefit with 100% cover, including an annual eye-test benefit and specific limits for optical items. Based on this information, I understood that I had an optical benefit available to me.

I recently went to Spec-Savers for my eye test and new multifocal glasses. The claim was processed with a medical aid portion of R3,685.50, with only R367.00 being my patient portion. I subsequently discovered that the entire R3,685.50 was deducted from my Medical Savings Account.

This means that the consultation, lenses and frame contribution were all paid from my savings.

I immediately queried this with PPN, who administer the optical benefit. Their response confirmed that the optical benefits are payable from available savings and that there are no separate funds allocated for optometry.

Most importantly, PPN subsequently acknowledged in writing that the wording in the brochure is not clear enough, stating that the wording makes it appear to a member that the eye-test amount is separate and not payable from savings.

This is not simply a request for clarification. I am disputing the processing of my claim because the benefit information presented to me does not clearly and accurately communicate that the stated optical benefits are entirely dependent on and deducted from my Medical Savings Account.

The benefit information states 100% cover and provides an annual eye-test benefit and specific optical limits. If these benefits are actually only available when a member has sufficient savings, that is a material limitation and should be clearly disclosed.

I also find it concerning that the administrator has acknowledged that the wording itself is unclear, yet the claim was still processed entirely against my savings.

I have already contacted Bonitas directly and requested that they formally investigate the matter. I am awaiting their response.

I am asking Bonitas to:

1. Review and reconsider the processing of my R3,685.50 optical claim. 2. Explain why the stated 100% optical benefits were not provided as represented in the benefit information. 3. Confirm whether the deduction from my Medical Savings Account was correctly app**** given the wording of the BonFit Select benefit. 4. If the claim was incorrectly allocated, reinstate the amount deducted from my Medical Savings Account. 5. Correct or clarify the benefit wording so that members can clearly understand that the optical benefit is subject to available savings.

I have supporting documentation, including my Spec-Savers invoice and written correspondence from PPN confirming that the wording is unclear.

I am not satisfied with simply being told that the claim was processed according to their internal rules. My dispute is that the benefit information provided to me did not clearly communicate those rules, and I am asking Bonitas to properly investigate and reconsider the claim.