Fedhealth refuses to pay claims even after approval

My son was admitted to the hospital on 10 February 2021 for Broncopneumonia. At the time, I had recently transferred my family's medical aid scheme from Discovery to Fedhealth. I understand that this time fell within the 3 month waiting period. However, this hospital admission fell within the Prescribed Hospital Benefits and should have been covered by the medical aid. I had even confirmed whether emergency hospital visits would be covered telephonically only a few weeks before. I have requested a transcript of this call

On admission, the medical aid would not at first authorise the admission and we had to pay the deposit in advance. The authorisation was processed shortly after and we were able to have the balance of our deposit refunded from the hospital. The remaining bill of R 12 389.66 we tried to claim back from Fedhealth but were told we had to wait until April when our benefits kicked in before the claim could be processed. We did this and then submitted the claim and the requested supporting documents. My wife continued to follow up with Fedhealth who told us that they would pay the hospital who we could then claim from. She continued to follow up and had the claim escalated to underwriting with no progress. I also tried to follow up and was told the claim had been escalated and that I would receive a response within 48 hours. One week later I still had not received a response.

I followed up again and was this time told that the claim had been approved and was waiting and pending. The consultant then kindly followed up further and told me the claim was not being payed out as the hospital had submitted incorrect dates on the claim. She informed me that I would need to contact the hospital to resubmit the corrected EDI claim so it could be processed. I contacted the hospital and and they comfirmed the codes they had on file were correct and then also resubmitted the account.

After further following up and no progress I submitted a complaint on 18 May 2021 and, although I received a notice that the complaint need additional information, we were contacted by Fedhealth and informed the claim had been authorised and would be paid out. All that we needed to do was ask the hospital to resubmit the claim and that would be it.

I did this and waited for a week before calling to follow up. I was told the claim had been denied as the hospital sent the claim with incorrect codes. I called the hospital and they checked the codes. They were fine.

I called Fedhealth again and was this time told that the claim had been rejected as the claim fell within the window period. The same issue we had when we first submitted the claim back in February that we had been told had been cleared up.

We have yet to receive the funds we payed out almost 6 months ago that should have been payed by Fedhealth in the first place.

I regret my decision to move to Fedhealth