FedHealth - Addiction or Death - Waiting for Approval

<p>My wife and I had moved up from Worcester to Kimberley in February 2014. We were blessed with the birth of our second daughter in March 2015, which got us thinking about our medical insurance status. We decided to investigate the option of upgrading from a hospital plan to a medical aid. We were insured with Discovery Health on the Coastal Core plan of which the coverage area boundary basically ends at Kimberley. So if we needed a prodecure to be performed in Bloemfontein we not be covered and would have to head to the nearest facility that falls into the Coastal Core Plan. We did research on various medical aids and packages and compared the benefits and prices and eventually settled on FedHealth Maxima Entrysaver. My wife joined Discovery Health in 2006, I joined Discovery Health in 2009 and our daughters joined at birth. In the 10 years that my wife has been a member of Discovery Health she has been admitted to hospital 4 times, once for a wisdom tooth extraction, once for a miscarriage and twice for the birth of our daughters. In the 6 years that I have been a member of Discovery Health I have never been admitted to hospital. In the 6 years that my oldest daughter has been a member of Discovery Health she has been admitted 3 times to hospital, once for pneumonia, once for a viral infection and once for a belly button hernia. In the 1 1/2 years that my youngest daughter has been a member with Discovery Health she has been admitted to hospital once for pneumonia. None of us are on any form of chronic medication. We are not a sickly family that require frequent visits to the doctors and hospitals. We take pride in the fact that we try to limit the claims to the hospital plan and medical aid as much as possible and that by doing so we are doing our bit to keep the yearly increases to a minimum. When we switched to FedHealth our broker at the time, Maggie Boshof, told us that FedHealth had app**** a 3 month general waiting period to the new policy which basically meant that we could not have any planned procedures done. I asked her if in the event of an accident we would be covered and she told me implicitly that we would be covered as our existing medical scheme (Discovery Health) was a member of the Council of Medical Schemes and that our new medical scheme (FedHealth) were also members of the Council of Medical Schemes and that both of them prescribed to the rules of the Council of Medical Schemes, so we would be covered for the 270 PMB codes and thereby in the event of an accident we would have coverage. We officially joined FedHealth on the 1st of July 2016. On Saturday the 13th of August 2016 my wife was working in the garden when a freak accident occurred which resulted in her nose being ripped away from her skull and replaced out of position. I was at work at the time of the accident and rushed home and collect her and my daughters and rushed with her to emergency / casualty at Gariep Medi-Clinic. We reported to admissions and my wife was ushered into the triage room where she was examined by a sister. We were then hand an examination report after which I went to admissions and my wife went through to the casualty ward and waited on the Doctor. When I handed the admissions clerk my medical aid card and she entered my details into the system I was told by her that my medical aid status is pending and that I would need to pay for casualty in full if I wanted my wife to be attended to. Fortunately, we had access to a facility and we were able to make the payment. My wife went for X-rays and was treated and was told by the Doctor on duty that she does not see anything significant in the x-ray but that my wife should see her again the following Wednesday and that should she not be better then the Doctor would refer her to the nose specialist. On Wednesday when my wife went for her follow up visit at the Doctor she was given a presciption for anti-biotics for sinasitis. My wife went back to the Doctor a week later as the infection in her sinuses had not cleared up. The Doctor then told her that she noticed that the septum was skew and referred her to Dr Sali who then referred her to Dr Hoek. Who then sent her for a CT scan and diagnosed the medical condition. He then told her that had the problem been diagnosed at the time of the accident that it could have been rectified but that now my wife would have to wait 6 months before he would be able to operate on her to fix her nose. All the while for all the above listed appointments and procedures we had to pay before anything would be done as our medical aid status still said pending. On the 8th of September almost a month after the accident my wife was still in severe pain and had developed a severe sinus infection caused by the blood, mucous and damage done to her nose from the accident and the inability to breath or blow her nose properly. Dr Hoek then admitted my wife to hospital so that he could give her intravaneous pain medication and anti-biotics to clear out the infection in her sinuses. I contacted Fedhealth for authorisation after numerous failed attempts by the hospital and obtained an authorisation number. The lady on the other end of the phone told me that my wife would be covered for the hospitalisation, take home meds, rehab after treatment, etc. After we checked out of the hospital FedHealth withdrew the coverage as the ICD 10 code was not a PMB code and was therefore not covered. When I called to find out as to why, after being harassed by the hospital for payment, FedHealth told me that the clinical department of FedHealth had made the decision that the code given was for sinasitis and that my wife could have waited for the 3 month general waiting period to be over before having the procedure done. My wife was scheduled for theatre on Wednesday the 21st of September to have her sinuses flushed out and a Nasopharyngoscopy. She did not go for the procedure as we wanted to sort out the prior hospitalisation before attemping to obtain authorisation for the pending procedure as we suspected that we would not be able to obtain authorisation due to FedHealth's clinical departments above response. We then moved the procedure to the 12th of October (3 month waiting period no longer applicable) during which time I have been in touch numerous times with Fedhealth to have the prior hospitalisation settled. I have had no luck, I keep getting shunted from pillar to post and do not get any further apart from having to tell my story over again to somebody new. All the while my wife is living in constant pain caused by blocked and infected sinuses. She lives on adco-dol pain medication, which is extremely dangerous as it contains codeine which can be addictive, to keep the pain under control. When I phoned FedhHealth this morning for authorisation for the procedure and hospitalisation they informed me that they will contact the underwriters and that they will get back to us in 48hours. Having to wait for 48Hrs to have approval granted or denied will not work for us as the planned procedure is for tomorrow morning, so yet again we have to postpone the procedure while we wait on approval from FedHealth. FedHealth have once again successfully been able to buy themselves more time and delay a client and patient the medical treatment that they need, deserve and pay for. So much for the 3 month general waiting period being over, as I was told that for the first year of the policy every procedure will be sent to the underwriters and that approval from FedHealth will depend on what the underwriters advise FedHealth. So, if I read between the lines my family and I have actually had a 12 month waiting period app**** to us, this is in direct contradiction of the rules of the Council of Medical Schemes. In all the years that we were at Discovery Health never once did we experience this kind of incompetance, malicious will to disapprove claims, blant time wasting tactics and the shear disregard for a client and patients health and wellbeing. I wholeheartedly regret moving from Discovery Health to FedHealth and would move back to Discovery Health without any hesitation but unfortunately my wife needs treatment and my only option at this stage is to stick with the devil I know and fight it out. I can only hope that by the time FedHealth decide to approve my wife for hospitalisation and her procedures that she is not addicted to codeine or dead from a sinus infection that spread to her brain. I strongly advise anybody who is considering FedHealth as a medical aid or hospital plan to reconsider their choice for the sake of themselves and their family's health and well being.</p>