You think you are covered for a serious accident - think again!

My husband and I are healthy; no chronic conditions and rarely sick. Like many people, we have Medical Aid because we want the reassurance that we are covered if the worst should happen. If you are the same, you are not going to like what I have to tell.

The worst did happen in May last year. My husband had a serious accident. He suffered multiple fractures and had to be rushed to hospital for immediate treatment and emergency surgery. He almost lost his leg. It was a terrible time but he pulled through and started the long road to recovery. Then the bills started coming. I'd estimate that the Medical Aid had paid maybe 20-30% of the bills and left us with over R300,000 to pay. They had either rejected or short paid most of the in-hospital bills.

Over the next six months, in between caring for my husband and trying to keep my business going, I started the process of querying the claims. Some I managed to get paid but others they flat out refused, including the extremely expensive external bone fixation device that alone cost more than R100,000. I had to get the Council for Medical Schemes involved. And here's the thing, after 6 months of daily queries and a ridiculous runaround from Bonitas, it took just one e-mail from the Council for Medical Schemes, asking for a justification for refusing the claims and Bonitas just paid up. There wasn't even a hearing or an investigation. THEY KNEW. They knew they were in the wrong and didn't have a legal leg to stand on. And this is what makes me utterly furious. Bonitas knew they were in the wrong but just hoped that if they held out long enough, I would just give up.

I'm still struggling to get subsequent claims paid and there is always a ridiculous reason. Sometimes they ignore the PMB codes on the statements, sometimes they capture the wrong information and sometimes they try to avoid paying by saying that there is no authorisation despite there being an approved PMB treatment plan in place. Getting a claim paid is like trying to get blood out of a stone.

The truth needs to be told. As a member or prospective member, you don't know how good or bad your medical aid is until you actually need it.