Misleading clients
<p>I am Rehana naicker. ID No ********** 108089, I have a clientele hospital plan. Since 2012. In 2014 when I requested claim forms on numerous times, I did not receive anything from clientele. When you try to claim. Clientele changes the terms on your policy and send you another policy document. Which was done to me. I have been hospitalized from 2016-11-14 until 2016-11-23. I phoned clientele a few days before admission to confirm if I could be admitted to ascot park hospital, because that's where my doctors go, seeing that I have a chronic illness, I could not go elsewhere, spoke to phindile hku also also. Who called me back and confirmed that I could be admitted there, and lodge a claim thereafter. I suffer with Trans Ischaemic Attacks and brain seizures. Whilst receiving treatment for the above, I developed heartburn on the 6th day of my hospital stay. I was sent for further tests. Whilst still being treated for TIA. Clientele turned down the claim stating that my illness is not serious. And I cannot extend my stay expecting the policy to pay out. If my medical aid approved these days. Does clientele have qualified doctors to diagnose my condition. I disclosed this illness at the inception of my policy. According to a clerk at clientele's independent arbitrator TIA is like (but not) a stroke. Lasts few minutes causing no permanent damage. Since she looked it up on the internet. She must ready the whole explanation. TIA is a mini stroke, prior to a full blown stroke if not treated. Tell her to read on brain seizures. I will send her my 15 page EEG. See how qualified she is to read it. And clientele says there was no objective to normal health. Why don't they say these things in their adverts. They are basically implying I stayed or extended my hospitalization to lodge a claim. I pay R308 a month. What for? Nowhere on there adverts do they say you have to be on your death bed, then only can you claim. According to bugwandeen my symptoms were listed as dizziness, visual disturbance, pins and needles and a heart attack. This is no objective to normal health. I have this in writing from clientele's complaints adjudicator, shasmikiran bugwandeen. I want to know her qualifications. Because clientele has been stressing me out in my medical condition for over 2 whole months. </p> <p> </p>
Our Independent Arbitrator’s office considered your matter and ruled that the rejection of the claim was appropriate because the medical information submitted did not support that you were suffering with the medical conditions described. The test result provided for the admission noted that there were no abnormalities. It is important to note that all claims must fall within the policy terms and conditions. This claim was excluded for the reason explained above, and this exclusion appears in your policy documents. Though, as explained in their response, should you be able to submit information supporting the admission, the claim decision can be reviewed.
Finally, it should be noted that the adjudicators in the Independent Arbitrator’s office have extensive experience in the assessment of claims, and make use of their own legal and medical knowledge, and also have access to internal and external consultants, to provide them with sufficient information to make their determinations. The decision of the Independent Arbitrator’s office is binding on Clientèle.
Therefore, if you are not satisfied, you may refer the matter to the Independent Arbitrator for review, or the industry Ombudsmen, as detailed in their letter.
Ryan Sacks
Independent Arbitrator
Office of the Independent Arbitrator
Our Independent Arbitrator’s office considered your matter and ruled that the rejection of the claim was appropriate because the medical information submitted did not support that you were suffering with the medical conditions described. The test result provided for the admission noted that there were no abnormalities. It is important to note that all claims must fall within the policy terms and conditions. This claim was excluded for the reason explained above, and this exclusion appears in your policy documents. Though, as explained in their response, should you be able to submit information supporting the admission, the claim decision can be reviewed.
Finally, it should be noted that the adjudicators in the Independent Arbitrator’s office have extensive experience in the assessment of claims, and make use of their own legal and medical knowledge, and also have access to internal and external consultants, to provide them with sufficient information to make their determinations. The decision of the Independent Arbitrator’s office is binding on Clientèle.
Therefore, if you are not satisfied, you may refer the matter to the Independent Arbitrator for review, or the industry Ombudsmen, as detailed in their letter.
Ryan Sacks
Independent Arbitrator
Office of the Independent Arbitrator
Thank u for ur response. Where in your advert does it state that u having to b on your death bed to claim. If I was informed if this I would not have taken your policy. And ur company changed my policy and sent me a new document as soon as I lodged a claim. If clientele thinks that brain seizures and TIAs are not serious medical conditions then I beg to differ. I have sent you my long EEG report ask your experts and consultants to read it if they can and then come back and tell me that my vital signs were normal. Show it to a qualified neurologist or Neuro surgeon and then give me your reply. I'm also awaiting a written apology from your department for implying that I extended my stay to claim on the policy. Your company knew of my chronic illness. Now you running away from payment when there is a claim. Do u or your company think, it's fun to stay in hospital and go through the discomfort of the tests. MRI, I'm claustrophobic. I'm also protein S Deficient with sinus venous thrombosis. As my medical accounts and reports for the past 5 years shows. And I have sent to u. Do u know what it feels like being in my forty's and having to.learn to walk and write, and not being able to put a puzzle together which a 2 year old child can. I'm on warfarin for life. That's Bcos the clots cannot heal themselves Bcos of protein S deficiency. Clientele is stressing me out over this claim. I pay R308 per month. Why does your adverts and consultants inform the public that you'll change the policy when there is a claim. And your company does not send out claim forms when requested , Bcos ul do not wanna pay out claims.
Thank u for ur response. Where in your advert does it state that u having to b on your death bed to claim. If I was informed if this I would not have taken your policy. And ur company changed my policy and sent me a new document as soon as I lodged a claim. If clientele thinks that brain seizures and TIAs are not serious medical conditions then I beg to differ. I have sent you my long EEG report ask your experts and consultants to read it if they can and then come back and tell me that my vital signs were normal. Show it to a qualified neurologist or Neuro surgeon and then give me your reply. I'm also awaiting a written apology from your department for implying that I extended my stay to claim on the policy. Your company knew of my chronic illness. Now you running away from payment when there is a claim. Do u or your company think, it's fun to stay in hospital and go through the discomfort of the tests. MRI, I'm claustrophobic. I'm also protein S Deficient with sinus venous thrombosis. As my medical accounts and reports for the past 5 years shows. And I have sent to u. Do u know what it feels like being in my forty's and having to.learn to walk and write, and not being able to put a puzzle together which a 2 year old child can. I'm on warfarin for life. That's Bcos the clots cannot heal themselves Bcos of protein S deficiency. Clientele is stressing me out over this claim. I pay R308 per month. Why does your adverts and consultants inform the public that you'll change the policy when there is a claim. And your company does not send out claim forms when requested , Bcos ul do not wanna pay out claims.