Declined Application, Poor service delivery

Good day.

I am diagnosed with diabetes and cholesterol and is on medication and now GEMS dont want to proces my application. How must I get my insulin and other pills, wife also need chronic medicine and my 4 kids needs medical aid. I'm working at Government hospital and GEMS knows that government employees are only allowed to use GEMS. Now they want to bully into paying for something that im not liable for. They don't care about me or my family, if we get sick or die. Its all about the money for them. They now blaming me for GEMS call center agents giving wrong information to members or doctors filing claims late.

On 4 April 2025 I mailed complaint to Gems as seen below. On the 11th April 2025 Phoned GEMS to get feedback then it was the same story. They transfer to the complaints department, then the debt department then back again then they say they have nothing to do with the debt it has been handed over to the lawyers on June 2024 , Ok ,they give me the lawyers details, I call them give them my ID no. and they say there nothing on their system that state that shows any Debt from GEMS, when I ask to email me prove, the lady said that she not allowed to email me prove. Now l call Gems back informing them and and now they say, members have a notice month and that the doctor filed the claims late - thats why it shows debt from 2023 on my profile on the system and must make arrangements and payoff debt before they can complete my application. My family needs to be on medical aid and it is frustrating and traumatizing how we are being treated. Gems need to complete my application and remove debt of my profile.

I am writing to formally lodge a complaint regarding GEMS's claim that I owe money. My previous membership number was ***.

I was a member of GEMS for almost 20 years and am appalled at the way I have been treated. As a government employee, I rely on GEMS for medical aid, and my experiences in 2023 and 2024 have caused significant distress and financial strain.

In 2023, my wife was pregnant, with her due date in November. I received authorization from GEMS for her maternity care and contacted your operators multiple times in July and August 2023. I informed them that I would be resigning from Stikland Hospital on 31 August 2023 and starting at Ceres Hospital on 1 October 2023. During these calls, I explicitly expressed my concern about continuity of coverage, given my wife's pregnancy.

I was reassured by GEMS operators that my medical aid would remain active. I was told I could continue using the medical aid as long as I submitted my appointment letter from Ceres Hospital, which I did. While they mentioned the possibility of extra fees, I agreed to this arrangement.

However, just weeks before my wife's due date, I was informed by a GEMS representative that my membership had been canceled and that I needed to reapply. Which I did. I was also told that the new membership would not cover the delivery. This abrupt change caused my wife and me immense anxiety and stress, as we had to bear the unexpected cost of an emergency cesarean section, amounting to approximately R65,000.

On 31 December 2024, I resigned from Ceres Hospital and transitioned to a private hospital, Vincent Pallotti, on 1 January 2025, using Discovery Medical Aid. By 1 March 2025, I had returned to government service at Stikland Hospital. However, my new application for GEMS was declined due to alleged debt on my profile. Upon inquiry, I was informed that in September 2023, GEMS had processed claims and now holds me responsible for those amounts.

I firmly believe this debt is unjustified, as I was assured by GEMS operators that my membership was active and valid in September 2023. Had I been informed otherwise, I would not have used the medical aid during that period.

To resolve this matter, I request the following:

That GEMS discards this debt from my profile. That GEMS retrieves and reviews all telephonic recordings of my inquiries with GEMS operators between July 2023 and November 2023, as these will clearly demonstrate that I was misinformed. That I receive copies of these recordings for my records. That my GEMS application is approved without further delay, given my long-standing history as a loyal paying member for nearly 20 years. That GEMS considers procedural improvements, such as providing members with copies of telephonic recordings immediately after inquiries, to ensure transparency and accuracy. I trust that you will address this matter promptly and fairly. Please feel free to contact me at *** to discuss this further or to provide updates on the resolution of this issue. Please contact me via ***

Kind regards.

Brendall Carolus.