COMPLAINT: ***

This was my email to GEMS ********** dated 28 November 2017 at 18:25 after yet another call to the GEMS enquiries line:

Good day Tasneem

My telephonic conversation with Asherita today 28 November 2017 refers.

Hereto my complaint as follows:

1. I contacted GEMS during May 2016 regarding a much needed operation that I had to undergo. Unfortunately I no longer have the details of the consultant or the reference number i was given.

I explained to the consultant that i need to under go an Orthognathic procedure in 2017 and that i need to undergo an operation to surgically remove some of my teeth in preparation for the said operation. At no time during the call was I informed that Orthognathics is a scheme exclusion.

I was however informed that i need to submit a motivational letter, scan and a quotation for pre authorisation approval. I sent this to ********** on the 13th of June 2017 and the operation was approved as per pre-authorisation dated the 22nd of June 2017. The operation was done on the 5th of July 2017. (Attached quotation, panoram xray, motivation letter as well as pre-authorisation letter).

After said operation i was left with a patient account of R902.40 for the panoramic xray as well as a R1 254.95 for the Anaethetist account which the medical aid did not settle and which I was liable for and which I paid in full. (Accounts attached).

Still there was no indication that GEMS would not pay for the Orthognathic procedure and I therefore continued with further treatment in preparation for the operation.

2. Further treatment involved Dental Models taken of my mouth and jaw on the 26th of May 2017, which amounted to R352.56, which i also settled in full. (Account attached).

3. On the 25th of July 2017 I had to do a CEPF scan with Orthodontist Dr Amos Lambrechts which also amounted to R472.00 which I was liable for and paid. All in preparation for the Orthognathic surgery.

4. I sent GEMS an email again on the 1st of August 2017 requesting pre-authorisation for the Orthognathic procedure and submitted the motivational letter and quotation for their consideration.

5. On the 3rd of August 2017 i received a letter GEMS informing me that the application was declined as it is a scheme exclusion. I called the Dental pre-authorisation department trying to find out what I can do to get the authorisation but was told that there is nothing that can be done.

I felt and expressed that should the medical aid not judge each case on its own merit as the operation was not for cosmetic purposes but a necessity for continued use of my jaw as it has been the cause of excessive pain and suffering since the age of 12. I felt that the medical aid has failed me at the time when i needed it the most. I even considered terminating my membership and seeking assistance elsewhere; as my complaint to GEMS dated the 3rd of August 2017 details. (Complaint attached).

6. On the 24th of August 2017 I spoke to Masego Asitile of the GEMS customer service centre and tried to find a common ground where GEMS could assist me and yet again to no avail.

7. On the 8th of November 2017 I had the opportunity to speak to a lady named Shiny Masemola, who I must admit tried her utmost to be of assistance to me and my situation. I explained my predicament to her and she found that the complaint I sent on the 3rd of August 2017 was never forwarded to the complaints department. She then forwarded the said complaint at 14:19 and Cc'd me in the email as well. I have to yet again thank her for her professionalism and assistance that she gave me.

8. Today, the 28th of November 2017, I contacted GEMS yet again as I have not receiced any feedback from the complaints department. I was attended to by a lady named Lebo as from 14:55. I explained the situation to her and regrettably she placed me on hold for more than 15 minutes in which there were intervals where I could hear her speaking in the background, only for her to continue placing me on hold.

9. I then called again and this time I was assisted by Asherita, who although she is fairly new with GEMS, was very professional and tried to assist me as best she could. I explained my situation to her and after follow up on the GEMS system she explained that there was nothing pertaining to my complaint on said system. After speaking to you she advised me to send you an email detailing the complaint as best I could as this process has been coming on for more than a year. I am very grateful for her listening s****s as I might have come across as very aggressive and she kept her composure right through to the end of the call. I truly wish that GEMS could have more consultants of her calibre and work ethic. Please thank her from me.

I sincerely hope that you can assist me as my health is very important to me. I was informed by my Maxillo facial surgeon that if I do not undergo this operation soon I face the risk of more health problems.

Thanking you in advance for your assistance.

Regards

After this email I am still none the wiser and even more frustrated than ever as I have not received any clarity as yet!

As can be expected I received an email from GEMS on the 15th of December 2017 at 17:08 stating the following:

Kindly be advised that your enquiry is under investigation. Feedback will be provided accordingly. This is regarding my complaint of the 3RD OF AUGUST 2017!!!!

THIS IS PATHETIC SERVICE AT IT'S EXTREME. AND TO DATE I AM STILL WAITING!!! YOU CANNOT EVEN CALL THE COMPLAINTS DEPARTMENT AS THEY ONLY HAVE AN EMAIL ADDRESS.... I wonder why that is?????

To be honest I am not interested in getting another " Please allow us a little time to investigate your complaint" line from GEMS.