Unacceptable Lack of Communication and Assistance

On the 19th of August 2020 we received yet another declined response on a PMB application for my 5 year old's paralysis. The line simply stated, "The request for outpatient physiotherapy and occupational therapy has not been authorised as the criteria for funding has not been met as it is not PMB level of care."

I have subsequently sent numerous emails to obtain clarity on the reason as PMB level of care means nothing to me as a layman and I requested for someone to revert with an in depth explanation as to why my daughter keeps being denied? I have reference numbers for each query. I have proof that the aPMB department and your customer care has read my emails.

No one has responded to my email since the 19th of August 2020 to explain in detail, why we are being declined. On 21 October 2020, Lizelle Pieterse advised that she would assist from her side to obtain an answer as I advised her of the above too. I sent her another email this morning. She responded stating that she'd emailed the medical advisors assistant, but have had no feedback from them. PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

any emergency medical condition; a limited set of 270 medical conditions (defined under Section 29(1)(o) of the Medical Schemes Act). and- 25 chronic conditions (defined in the Chronic Disease List). We are not applying for CHRONIC DISEASE PMB for the paralysis – we are applying for the PMB as a MEDICAL CONDITION from the 270 conditions defined under Section 29(1)(o) of the Medical Schemes Act. I have asked on countless occasions what is required from us. If we have the wrong ICD10 code for the paralysis, then please say so, so we may have it rectified. I have sent every document, report, doctor's motivation letters etc that you have asked for. The lack of communication is unacceptable and is hampering recovery and possibly causing more damage and longer lasting effects on my toddler because Fedhealth is not forthcoming with their information. Please respond.