They Don't pay medical bills

I am writing to express my deep frustration and concern regarding the manner in which my medical aid contributions are handled in contrast to the medical benefits I receive. I pay my monthly premiums diligently and on time. I am a healthy individual and have not been hospitalized in many years — not even for a single day. Yet, when essential medical procedures are required, such as my recent urological examination and blood tests for cancer screening, these are not covered by the scheme. It is becoming increasingly difficult to understand what the medical scheme does and does not cover. Despite numerous attempts, I am unable to get a clear answer. There always seems to be a reason or excuse for non-payment. Medication must be paid from savings, which are quickly depleted. On top of that, we are compelled to purchase gap cover because the medical aid does not pay 100% for hospitalization and other critical services. This raises the serious question: what exactly am I paying for? Furthermore, it is disheartening to see that although medical schemes are meant to operate as not-for-profit entities, they collect premiums religiously while making minimal effort to pay out for necessary healthcare. This appears to place profit above patient well-being. Frankly, I feel misled and angered by a system that causes unnecessary stress — stress which in itself raises my blood pressure, for which, ironically, the scheme also refuses to pay for treatment. It now seems far more logical to abandon comprehensive cover altogether and simply opt for a hospital plan with gap cover, which may offer better value and fewer complications. Please advise urgently: What exactly does my plan cover — in clear, understandable terms? Why were the recent tests and specialist consultation not paid for? What steps can be taken to escalate this matter within your organization? If I do not receive satisfactory answers, I will be left with no choice but to refer this matter to the Council for Medical Schemes or the Medical Ombudsman.