Essential Med makes denying authorisations an essential part of their service.

My son injured his knee at an indoor soccer game on the 14th of May. On the 15th I took him to one of Essential Med's network Doctors to have a look at it. He prescribed a 10 day course of an anti-inflammatory and advised us to come back should that not help. On the 25th of May we were back in the Dr's rooms the swelling had gone done but he was still in some pain and his knee would give way under him when doing simple activities like walking. He suggested we see a specialist, he suspected that it was an injury to his lateral collateral ligament but was not certain. I was only able to get an appointment for the 12th of June. I saw the specialist on the 12th when he diagnosed my son with a anterior cruciate ligament tear. We returned on the 15th where we were advised that he would require an operation to repair the tear.

I made a preliminary booking and they assisted with getting costs for me to submit to Essential Med. I emailed my usual contact (Chantelle Pedro) on the 20th of June to find out if the costs where covered. I received no response. I emailed her again on the 25th of June - still no response. I then called the Essential Med call Center on the 28th of June when I was asked to please email the information to the africa-assist authorisation email address.

On the 28th at 1:42pm I received a call from Mohammed asking me when my son was initially diagnosed as he had some conflicting information - the Specialist's rooms had said that he had been diagnosed on the 15th and I had submitted a claim on the 12th which I said to Mohammed was probably just an honest mistake on their side - I found out later when I called the Dr's room's that Mohammed had confirmed that with them as well (so why call me to confirm - was he expecting to catch me in a lie?) I called the rooms as well and they said they would happily correct the error and apologised for it. I mean we all make mistakes I could not remember dates when I was discussing the injury telephonically.

During my call with Mohammed he also mentioned something about a different ICD10 code being entered on one document meaning that it was for a right knee and another code being entered for a left knee. I later found out that the GP had submitted a code 19.0. The GP has since explained to me that due to the fact that my son now suffers from instability of his left knee which affects the other muscles and ligaments in his leg that is why he used code 19.

I was called back at 3:42pm on the 28th and advised that the operation would not be authorised due to the following: 1) the Specialist had said that he was disgnaosed on the 15th and not on the 12th, 2) there was a discrepancy with the codes and whether it was a left knee or a right knee and 3) that I had not called Essential Med within 48 hours after the "accident" to advise them that there had been an injury and I might need to make a claim.

Now that you have the background here comes the crux of the matter. Telephonically I was told the order of reasons why authorisation was declined was as above. When I asked for an email explaining why it was declined the first reason was number 3 above. I explained to Elize at Essential Med that at no point was I advised that I needed to contact Essentail Med within 48 hours - I have gone through the Essential Med site, emails received when going through the application process as well as my policy document and cannot find ANY reference to a 48 hour deadline. So basically I am supposed to smell that if I fall at home after twisting my ankle and knock my knee against a wall I am supposed to call Essential Med within 48 hours and advise them that I have injured my knee and my ankle and I might have a claim later on?

I get the feeling that Elize gets a bonus for declining authorisations and is throwing as much mud as possible to see how much can stick to make sure that authorisation will be denied. I am unwilling to accept that this is the final say in this matter.

I was one of their biggest fans and promoted them to all my family and friends NOW I have advised them all that they should spread the word that Essential Med tries their best not to pay claims especially seeing as I have found out how long they take to make payments to Doctors within their very own network.