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Asibabale N

1 reviews | Active since Jan 2012

22 May 2018, 09:32

Delay in reimbur*****t of claims

I am aggrieved by Gems conduct when it comes to reimbursing us for our claims. The medical aid doesn't pay the Psychologist and I settled my bill after receiving numerous smses from GEMS that I should pay the doctor and claim back from the medical aid. I did so but still haven't been paid back. I have been making follow ups by phone and email and still no response instead I was told the matter is under investigation. How long do these invitations take? I am even scared of going for therapy now cause I am left with bills to pay and the worst is I was admitted in hospital and the psychologist was not paid for consultations whilst in hospital. someone please help me

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Replies (9)
Gems (Government Employees Medical Scheme)
Gems (Government Employees Medical Scheme)'s reply22 May 2018, 11:35
Official

Good day

Thank you for the opportunity afforded to us to respond to your concerns. We are investigating this matter and will revert soonest.

Kind regards

The GEMS online team

AN
Asibabale N's update24 May 2018, 07:46
Reviewer Update
Good morning How far is the investigation? I haven’t received any communication from the GEMS team. Please provide an update.
AN
Asibabale N's update29 May 2018, 08:04
Reviewer Update
Good day I am still waiting for an update on my 2018 claim. No response has been given with regards to that and my email are not responded to. It’s sad that we constantly have to make these follow ups and we are not even being responded to. What else should we do? Please advise
Gems (Government Employees Medical Scheme)
Gems (Government Employees Medical Scheme)'s reply04 Jun 2018, 15:31
Official

Good day

Thank you for affording GEMS the opportunity to respond to your claims query.

After a thorough investigation, we can confirm that we require an amended account which reflects the referral provider’s practice details.

Please note that all claims are paid at the GEMS Scheme rate in accordance with Scheme Rules, member's available benefits and in line with clinical protocols. In instances where the provider is charging more than the Scheme rate or your benefits are exhausted, the member is responsible for paying the difference.

We look forward to receiving your account.

Yours in service,

The GEMS online team

AN
Asibabale N's update06 Jun 2018, 14:06
Reviewer Update
Good day The practice has sent you the amended account on Monday and I also forwarded it to you yesterday and today and there is still no response. What will it take for this request to be heard?
AN
Asibabale N's update06 Jun 2018, 14:11
Reviewer Update
It’s almost a month now of following this claim. You take time to respond you just don’t care about your clients. We constantly have to chase you for our monies yet you never get a bounce when you deduct your premiums. You need to pull your socks up and stop this running around sending your clients from pillar to post.
AN
Asibabale N's update08 Jun 2018, 11:00
Reviewer Update
Good day You keep on sending me letters about a reffering doctor. As I mentioned to the caller that called me earlier regarding this account. I was not referred by any doctor to see dr Xoli Mvoko (the Psychologist) I booked myself an appointment and went and saw her. She then referred me to the Psychiatrist. I am not sure what is it that is not acceptable by what I did. I have gone and consulted with Dr Mvoko in 2016 and I was helped by her therapy. This year I did the same but I was in a more worse condition hence I ended up being admitted.
AN
Asibabale N's update08 Jun 2018, 11:04
Reviewer Update
So are you saying it was wrong for me to go and see a Psychologist without being referred by a doctor? Please be clear so that when I take this matter further I have a clear response from you regarding your rejection of my claim and the fact that I booked myself an appointment to see a Psychologist.
AN
Asibabale N's update13 Jun 2018, 09:11
Reviewer Update
What referral GP are you talking about? I voluntary went and saw a Psychologist before I was hospitalized and I was hospitalized and saw a Psychologist together with the rest of other professionals i.e Psychiatrist, Social Worker and Occupational The******. Why is it an issue to pay a Psychologist and not the rest? You sent me an sms to pay the Psychologist and claim from the medical aid. Why did you do that?