Title: URGENT – Medical Aid Refusing to Pay Legitimate In-Hospital Emergency Claims

I am extremely disappointed and frustrated with the ongoing issues regarding several medical claims that my medical aid is refusing to settle — all of which occurred in hospital and should unquestionably have been covered.

Emergency Gallbladder Procedure – Husband My husband had to undergo an emergency gallbladder removal earlier this year. During the procedure, complications arose and the surgical team had to perform the procedure twice, immediately, to prevent further harm. I now have an outstanding amount of approximately R1,300 that the medical aid refuses to pay because they claim the procedure was “done twice.” It was an emergency. There was no option to delay this or seek prior authorisation. It was life-threatening, and the doctors had no choice but to take immediate action. The refusal to pay this claim is completely unacceptable.

AMPATH Account – ±R300 I have also received a pathology account from AMPATH (approximately R300) for tests that were done while my husband was admitted in hospital. There is no valid reason why an in-hospital pathology test should be rejected.

Child’s Hospital Claim – ±R3,000 Earlier this year, my child was admitted to zuid Africans for treatment, and I now have an outstanding bill of approximately R3,000 that the medical aid is also refusing to pay. Again, this was an in-hospital event, and there is no justification for these rejections.

I have already sent an email requesting urgent clarity, and I have received no response whatsoever. The lack of communication is unacceptable, and the refusal to pay legitimate in-hospital and emergency claims is deeply concerning.

I am requesting the following immediately:

A full explanation as to why these legitimate claims were rejected.

Immediate reassessment and settlement of all outstanding amounts.

Written confirmation that these in-hospital and emergency claims will be covered as per the medical aid rules.

I am placing this complaint here because I am not receiving assistance through normal channels. I expect urgent feedback and resolution