BAD SERVICE

I am a Financial Advisor and have been working with a number of medical aids over the past 8 years with regards to claims, authorisations, motivations for chronic meds etc. and understand the process quite well. I have been trying to assist a member who is on the Emerald plan to get authorisation for chronic medication for her son's Schizophrenia since the 4th July 2018 - he has tried quite a few meds and the one that he is on currently, that we are trying to get authorised (member pays cash) - has had the best results. I have a signed consent to obtain information and an agent in the Chronic Auth department has a recorded telephone call where the member confirms that I have access to the information. Medication that has been prescribed by the Psychiatrist is on the Comprehenisve formulary "Accepted treatment (clinical motivation for low-cost options) she is not on a low cost option. Original motivation was sent through in August last year - medication declined "DOES NOT QUALIFY" member was never advised why, no elaboration on the outcome or what she would need to do to resubmit the motivation for consideration! Since the 4th of July 2018, 18 calls have been made to GEMS ranging between 30 mins to an hour and a half or more, for assistance with the updated motivation, what a stress!!! Agents are not very clear when advising what they need for the motivation to be reconsidered. Agents will not speak to me and put me on hold till I have to hang up and call again. Agents want the member to call in and deal with all the "Medical Jargon" that she does not understand! An updated motivation was sent on the 3rd August 2018, according to GEMS nothing received. Resent on the 3rd August 2018, we received confirmation of receipt with ref. number via email from GEMS. Followed up on the 13th August 2018, motivation received but not captured!! (supposed to take 5 days to capture, would it still not have been captured if we did not call in to follow-up?). Motivation sent for capturing. Follow up today, consultant not willing to speak to me even though there is a voice recording between GEMS and member that I have access to the membership and notes on the system. When I ask to speak to management I am transferred and on hold to the point that I have to put the phone down and call again. The service is terrible, very frustrating, ! I feel really sorry for members who have to deal with GEMS that do not understand the jargon. I wonder how many of their members try to claim and then just give up because of the amount of calls they have to make to the scheme as well as nothing being explained to them?