Fedhealth not covering PMB conditions

This is an email exchange between Fedhealth consultant and client on 19 May 2021 :

Fedhealth consultants response : 1. There are 26 PMBżs, which are your chronic conditions and 271 are for procedures eg. Car accidents

Frustrated customer reply : I wonder if your not confused between 26 pmbs and 26 cdl. Does Fedhealth have its own pmb conditions? As far as I know the list of pmbs are decided on by the medical scheme act and not by Fedhealth. Are fedhealth also now another council for medical schemes who determines the pmbs? Go visit the cms website and get your facts straight,you are trying to mislead me. The cms website list 25 chronic conditions not 26. They do list 271 pmbs ,which you say is only for procedures like accidents. In that list is diabetes and stroke(CVA) .these are illnesses ,not accidents. The cms website said the pmb condition must be covered for diagnosis, treatment and care , not just procedures like accidents. There is also a third category of conditions that must be covered by all schemes and that is an emergency medical condition.You are confused between the pmb category and the third category(emergenies)

Fedhealth consultants response : I do apologize for not providing you with the list whilst on the phone however the line was not clear and could not pick up the type of specialist you required, the internist falls under specialist physician (specialty 18) I have attached list of service providers on the network.

Thank you for the list

Fedhealth consultants response : The provider or member can apply for chronic medication telephonically or send the script on email to ***

Frustrated customer reply :You did not respond to the second part of my comments. And just like the list of service providers that you did not think of to send me,now you also do not provide me with the phone nr to apply for chronic.

Fedhealth consultants response : Specialist consultation are payable from savings/wallet subject to scheme rules and benefits. Once the treatment plan is approved and loaded member can request for the claim to be reprocessed and paid from the PMB benefit. In a case where the member paid cash to the service provider. You can submit the invoice and proof of payment to reimburse you.

Frustrated customer reply :Go and read my question again. You dont say if the stroke falls under your pmb conditions, are you talking about your own fedhealth list of pmbs or of the 271 pmbs stipulated by the act? Are you saying the first specialist consultation can be covered and those afterwards also once the treatment plan is approved?

Fedhealth consultants response : Additional chronic conditions either than the 27 PMBs are covered additionally up to a set limit and is dependent on the option selection by the member

Frustrated customer reply :First you say 26 ,now its 27 ,it should be 271 pmbs. And the act says the 271 pmbs must be covered by all med schemes irrespective of option selection. How many times must I say this? and you did not answer question nr 6.

With regards to the Family room I will get a consultant from the relevant department to contact you.

Fedhealth consultants response : CT scans and MRI are payable from the risk benefit unlimited at Fedhealth rate, an authorisation is required prior the treatment. There is a co-payment payable to the hospital account of R2380.00 (in a PMB case this co-payment can be reviewed by the scheme upon receipt of scan results)

Frustrated customer reply :Your fedhealth brochure does not say the co-payment will be reviewed for a pmb condition scan ,they only say theres a co payment for non-pmb ,not for pmb conditions ,fedhealths marketing is misleading.

Fedhealth consultants response : The plan that your parents are on FlexiFed 2 grid GP consultations are payable from savings/wallet. Once you have reached the threshold level unlimited consultations with nominated GP consultations will be paid from your overall risk benefit.

Frustrated customer reply :I can understand theres no gp cover for non pmb conditions ,but why should a pmb condition be paid through the savings? Then it becomes a loan that must be paid back , The law stipulates that pmb conditions should covered , and not settled like a loan,thats not cover,how many times must I repeat this?

Frustrated customer comments. :Conclusion : The inaccuracy of your facts and blatant ignoring many of my questions and comments is pathetic. I will convert this email into a more understandable dialoque and put it as another review on hellopeter.

Eugene