HOSPITAL CLAIM NOT PAID OUT AFTER 35 DAYS

My wife has a Clientele hospital cover which pays out when you are hospitalized. August 28th 2017 - She visited a GP with a rash on her face, ulcers on her ears, fingers and ears. Dr referred her to hospital as he said this looks like lupus but only blood tests can confirm this. 30th August 2017 - She got an appointment with a Rheumatologist, he advised that she has lupus and vasculitis 31st August 2017 - She was given chemo therapy to help her immune system. 12th September 2017 - She had a follow up and it was not good. Dr advised that her condition worsened and she needed to be admitted. She needed aggressive chemo therapy. She was in hospital until 17th September 2017. During this time, she was further diagnosed with Antiphospholipid syndrome and Panniculitis. This alone was a very big diagnosis and had an impact on her. She stayed long periods off work as a result of side effects from chemo. Her symptoms worsened each day.

16th November 2017 - she suffered 3 attacks which looked like seizures. She had a previous history of epilepsy so I rushed her to hospital. She got admitted by the doctor on call, a psychiatrist. We informed Clientele, the next day. An assessor called her, Thandeka ( Thandi), whom advised her that Clientele does not pay for psychiatry ( we were well aware of that ). After completing MRI's and EEG's it was panic attached and not seizures. She advised the assessor of same. Thandi was extremely helpful, understood the situation and RETURNED calls when messages were left. It was also stated that Clientele will not pay for psychiatry but if the cause arose from an illness then yes, there is a possible claim. PLEASE NOTE THAT BEING DIAGNOSED WITH LUPUS, VASCULITUS, PANNICULITIS, ANTIPHOSPHOLIPID SYNDROME, EXCESSIVE BLEEDING AND A MUCOUS CYST IN THE BRAIN IS NOT CHILD'S PLAY.............will this not affect a person psychologically??????

6th December 2017 - Although she was still in hospital, the hospital closed that file and re-opened a new file on December 7th. 7th December 2017 - She went for an endometrial ablation due to her excessive bleeding. 18th December 2017 - She was finally discharged from hospital.

Since then we comp****, sent all the necessary documents. On our side all notes were as clear as day. We printed both in colour and black and white and it was clearly visible. This claim went on for a while, then it was said she will be paid an amount of R7000.00. After enquiring why only R7000.00, they changed and said due to a long stay, they require file records. This was supp**** but she was told that it was blurry. By this time Thandi had gone on leave. We spent alot of money phoning Clientele, leaving messages DAILY ( 3 to 4 times in a day ) but nobody will call back. On one hand you get an agent who will transfer you to the assessor and there are others that say they cannot transfer. Due to my wifes files being so large, the hospital advised that they require a payment of R3500 for us to obtain these documents. My wife being the provider at home has not earned a salary in the last 3 months........where were we to get this sum of money?

19th January 2018 - we called in, we told Clientele again that when we printed the documents on our side it is clear. With no other options, we asked for their address to hand deliver documents. After providing the address, the consultant said "yes, you can hand deliver, but we will need to scan and attach so it will not be clear. Despite that, she said we will deliver it. Just then, the matron contacted us saying they will send documents. We received it and immediately sent it through. My wife called them to advise that it was sent. The consultant confirmed that he received same, he will attached immediately and send.

22nd January 2018 - She called Clientele, they stated that documents were only attached and sent this morning to claims. My wife advised that the consultant said he will send same on Friday, he said it was not sent and only sent this morning. She called them 5 times asking for the assessor to call her back. Each time they said they escalated it but we received no call.

23rd January 2018 - My wife called just after 8am, she was told matter was escalated and it has been assigned to Nkonzo Mazimula......again no call.......at 11h37 she called again. She left another message to be called. At 12h02, he called stating that he has repudiated the claim as its psychiatry. She explained the conditions and advised him that it was not psychiatry. But he refused to listen. He said he will send a letter of repudiation and if she is not happy, then she can take it up. She then advised him that ok......if he says it was psychiatry, then what happened on the next file 7th December onwards, when she went to theatre.......he still went on to say she must respond on the letter.

This hospital plan from Clientele feels like a money making scheme. They look for every possible reason NOT TO PAY THE CLAIM!!!!!! This is not a diagnosis of a flu......this is my wifes life. The initial cause of her having those attacks was stress DUE TO THE DIAGNOSIS. This was really unfair, we have incurred unnecessary costs to obtain these documents and large amounts of airtime to call them.........all this was done on borrowed money and FALSE HOPE THAT THIS CLAIM WILL BE PAID. Furthermore they have FALSE ADVERTISING WHERE THEY SHOW THAT YOU RECEIVE MONEY WHILST ON A HOSPITAL BED........THIS IS HOGWASH.......because it took them 35 days........and repudiated the claim.