1 reviews | Active since Mar 2017
Misleading terms - poor customer service
I have joined Essential Med for just over a year now. My policy states that I have unlimited GP, dentistry and optometry visits (after applying the stipulated waiting periods). Upon visiting a GP and dentist in their network I was still given a bill to pay the difference between what is actually covered and what is not. Upon inquiring from Essential Med, Radine Beukes, informed me that the third party service providers know exactly what is paid out by Essential Med and what is not. I informed her that I am very happy they the problem is I do not know. As a consumer I am entitled to know the full extent of my coverage, what procedures/products/services are covered and the extent of such coverage. I believe Essential Med utilizes false advertising mechanisms to mislead its customers which conduct must be in breach of the Consumer Protection Act.
I am also contemplating visiting a optometrist as provided for in my policy - as it includes an eye test, lenses and a frame. Upon inquiring from Essential Med if their is a frame price cap (as my policy does not specify this) I was once again informed by Radine Beukes that Essential Med makes sole use of Specsavers and that the frames are capped at R150.00. I was dumbfounded as Specsavers does not even sell frames for under R700.00. I was once again mislead in believing my policy covers frames however it only affords me a measly contribution by Essential Med. This is completely unacceptable! I am giving Essential Med the opportunity to stop ignoring me and the opportunity to resolve this matter expeditiously and amicably failing which I shall approach the Consumer Tribunal and/or any other avenue at my disposal.
Good day,
Thank you for bringing your concerning matter under our attention.
Essential Med is a Medical Health Insurance and not a medical aid.
Referring to the quotation that you as member received shows what benefit is available to you as member. The levels indicates what benefits is available.
Before a member is assisted at any provider the practices needs to phone to confirm benefits.
On the quotation the following was stipulated for Dentistry:
Benefit Level 2
Managed unlimited dentist consultations and procedures as per formulary, including cleaning, pain control, RESIN fillings and normal extractions. Also: 1 Root Canal Treatment to the value of R2000 per event per beneficiary within a 12 month period. 1 Crown per beneficiary to the value of R4500 per event within a 24 month period. These services are obtained from an Essential Med network registered provider. 6 month waiting period applies.
Optometry:
Basic Optometry & Vision- Your Optometry benefit includes an eye test per beneficiary and free single vision lenses and frames every 24 months. 12 month waiting period applies.
Specsavers is aware of the benefits for Optometry for Essential Med members. We cover according to the PPN 1 benefits.
Essential Med strives in the best service delivery towards all our valued members.
Kind Regards,
Essential Med
Good day,
Thank you for bringing your concerning matter under our attention.
Essential Med is a Medical Health Insurance and not a medical aid.
Referring to the quotation that you as member received shows what benefit is available to you as member. The levels indicates what benefits is available.
Before a member is assisted at any provider the practices needs to phone to confirm benefits.
On the quotation the following was stipulated for Dentistry:
Benefit Level 2
Managed unlimited dentist consultations and procedures as per formulary, including cleaning, pain control, RESIN fillings and normal extractions. Also: 1 Root Canal Treatment to the value of R2000 per event per beneficiary within a 12 month period. 1 Crown per beneficiary to the value of R4500 per event within a 24 month period. These services are obtained from an Essential Med network registered provider. 6 month waiting period applies.
Optometry:
Basic Optometry & Vision- Your Optometry benefit includes an eye test per beneficiary and free single vision lenses and frames every 24 months. 12 month waiting period applies.
Specsavers is aware of the benefits for Optometry for Essential Med members. We cover according to the PPN 1 benefits.
Essential Med strives in the best service delivery towards all our valued members.
Kind Regards,
Essential Med
Good day,
The Dental benefit has a break down of what is covered on the level and it states the formula however we don't have access to this. The provider need to contact our administrators in order to confirm codes and amounts before they assist.
Regarding the optometry PPN1 is a Guideline which we cover and as advised Specsavers needs to stay within this guidelines in order to make sure that they do not go above the agreed amounts.
Essential Med strives in the best service delivery towards all our valued clients.
Kind regards,
Essential Med
Good day,
The Dental benefit has a break down of what is covered on the level and it states the formula however we don't have access to this. The provider need to contact our administrators in order to confirm codes and amounts before they assist.
Regarding the optometry PPN1 is a Guideline which we cover and as advised Specsavers needs to stay within this guidelines in order to make sure that they do not go above the agreed amounts.
Essential Med strives in the best service delivery towards all our valued clients.
Kind regards,
Essential Med
Good day,
Please be advised that Specsavers need to contact the administrators once you have made an appointment for Optical benefits.
Optical benefits is as follows depending on the level that was chosen by you as member:
CONSULTATIONS
A consultation consists of Refraction, Tonometry, Visual field screening and Dispensing within the benefit, at an approved provider to the value of R469.
SPECTACLES
Frames: R150 Frame or lens enhancements (SAOS frame code 40501)
Clear Spectacle Lenses:
Single Vision Lenses 2 x R165.00 per lens (SSSA code 80001)
OR
Bifocal Lenses 2 x R360.00 per lens (SSSA code 80002)
OR
Multifocal Lenses 2 x R660.00 per lens (SSSA code 80003) but covered up to the limit of Bifocal lenses: 2 x R360.00 per lens,
member to pay the difference between MF and BF cost
OR
Contact Lenses 4 packages of contact lenses valued at R350.00 per package is available once every 6 months in a 24 month cycle
The benefits are subject to the below criteria:
1. No cover for single vision Rx < 0.50 diopter
2. No cover for bifocal/varifocal < 1 diopter
3. Bifocal/ varifocal lenses for adults under the age of 40 years old, must be motivated
4. No varifocals for children under the age of 18, except in the case of post cataract surgery. Bifocals must be motivated.
Kind regards,
Essential Med
Good day,
Please be advised that Specsavers need to contact the administrators once you have made an appointment for Optical benefits.
Optical benefits is as follows depending on the level that was chosen by you as member:
CONSULTATIONS
A consultation consists of Refraction, Tonometry, Visual field screening and Dispensing within the benefit, at an approved provider to the value of R469.
SPECTACLES
Frames: R150 Frame or lens enhancements (SAOS frame code 40501)
Clear Spectacle Lenses:
Single Vision Lenses 2 x R165.00 per lens (SSSA code 80001)
OR
Bifocal Lenses 2 x R360.00 per lens (SSSA code 80002)
OR
Multifocal Lenses 2 x R660.00 per lens (SSSA code 80003) but covered up to the limit of Bifocal lenses: 2 x R360.00 per lens,
member to pay the difference between MF and BF cost
OR
Contact Lenses 4 packages of contact lenses valued at R350.00 per package is available once every 6 months in a 24 month cycle
The benefits are subject to the below criteria:
1. No cover for single vision Rx < 0.50 diopter
2. No cover for bifocal/varifocal < 1 diopter
3. Bifocal/ varifocal lenses for adults under the age of 40 years old, must be motivated
4. No varifocals for children under the age of 18, except in the case of post cataract surgery. Bifocals must be motivated.
Kind regards,
Essential Med