Rulings was made twice by council and my daughter has a PMB condition it is clearly that the best well being of their members is NOT a priority as for a year a still had to pay PMB nappies which was suppose to be funded by THEM

Please note that the first CMS case it was clear that you must fund the diagnosis, treatment and care of the condition…. Is nappies not seen as care of a PMB condition, whilst in the same sentence you have told me that it should be funded as PMB as per CMS and that was the email received on 18 January 2024.

It seems that we are now extending and extending time to not pay what is due to my daughter and to get this resolved and her nappies paid?

For a second time I had to include the CMS as it was then all of a sudden unclear as to what the scheme meant by the first ruling however it was clear when your agent admitted it in an email that it should be PMB

All I want now is:

- for nappies to be funded as per ruling. - My re-imbur*****t as per attached ( Into my new bank account ) - Either Ex-gratia payment from January 2024 till date or a minimum of 5 pack nappies per month over a period of 11 months that need to be re-imbursed as the ruling stayed the same, you were aware of this but was looking for excuses not to pay this?

Dear M Louw,

Thank you for your email.

Your reference is: 250324Q3XH4Z.

Kindly refrain from including the scheme's email addresses in the correspondence that you send to The Council of Medical Schemes as this creates invalid / duplicate queries in our departments to which we cannot provide a response to at the moment.

The current ruling from CMS is clear in respect of the instruction to fund the orthosis, which has already been resolved. Further, the PMB definition as per the Regulations indicate that PMB includes the diagnosis, treatment, and care of the condition. The care component includes physiotherapy, occupational therapy, and all other ambulatory services.

However, it is not clear what sort of ambulatory services must be considered as treatment within the provided guidelines above, therefore, you were referred to appeal the matter to CMS for further clarity and definition of the ambulatory services in the provided ruling.

The funding instruction should be clear and must provide sufficient reference to any limitations or restrictions that should apply to the funding.

The scheme must await further feedback, communication and/or instruction from CMS to proceed further with this case.

Once you have received a response from CMS, you may refer the request back to the scheme via email to *** for further attention and review.

Please visit www.fedhealth.co.za to access the Fedhealth Family Room for claims, benefit information, download important documents, to add & remove dependents, and much more.

In an effort to assist you even better Fedhealth has launched a WhatsApp platform for quick self-help service, the service can be accessed on the following link: https://wa.me/***.

To open communication from Fedhealth with an attachment you will be required to enter the main memberżs ID or passport number.

Kindly update your personal details on a regular basis, to ensure that you receive the latest updates from Fedhealth. Should you require any further assistance, please contact the Fedhealth family on ***or ***.

Best wishes, Amore Meyer High Level Query Specialist: Executive Office