FOLLOW-UP COMPLAINT: GEMS – NO FEEDBACK ON EX GRATIA AND MENTAL HEALTH BENEFITS

I am submitting this as a follow-up to my previous HelloPeter complaint against GEMS because I have still not received a satisfactory and substantive response addressing the issues I raised.

In particular, I remain extremely concerned that the matter concerning my mental health benefits has not been properly addressed.

My previous complaint clearly raised my ongoing difficulty in accessing mental health services and the problems I have experienced with claims and authorisations relating to my psychological and psychiatric treatment. Despite this, I have not received a clear explanation from GEMS regarding:

I am also still awaiting proper feedback regarding my Ex Gratia application. This matter has been outstanding for an unreasonable period, and the previous response did not provide me with a clear final outcome or adequate explanation.

I therefore request that GEMS provide a written, point-by-point response to each of the above issues rather than a generic response stating that the matter is being attended to.

This is not merely an administrative or financial dispute. The unresolved mental health benefits issue directly affects my ability to access necessary healthcare and continue with treatment.

I have already made repeated attempts to resolve these matters through the appropriate GEMS channels. I should not have to repeatedly lodge complaints simply to obtain clarity on benefits that are directly relevant to my healthcare.

I therefore request that GEMS urgently:

If GEMS maintains that any of these benefits or claims are not payable, I request that this be clearly explained in writing, including the specific benefit rule, limitation, exclusion or PMB determination re**** upon.

I would appreciate a substantive response to the actual issues raised, rather than another general acknowledgement.

The fact that I have had to follow up repeatedly without receiving a clear resolution is extremely frustrating, particularly when the outstanding matter concerns access to mental healthcare.

I reserve my right to escalate the unresolved matter to the appropriate external dispute-resolution and regulatory bodies should GEMS fail to provide a satisfactory response.

I request that this complaint be treated as an escalation of my previous complaint and that the outstanding mental health benefits and Ex Gratia issues be addressed urgently.

GEMS must answer the actual complaint

Thank you for the response, but unfortunately this does not address the substance of my complaint. I do not want another generic response directing me to submit information that GEMS already has on its records.

I am specifically requesting a written, substantive response on the following:

The request for my GEMS membership number and claim details appears to be an attempt to move the discussion away from the actual complaint. GEMS has my membership details, ID information and claim history on its systems and should be able to identify my claims from its records. If there is a specific piece of information genuinely required to identify a particular claim, please clearly state what information is missing and why GEMS cannot obtain it from its own records. Most importantly, I am not asking for another acknowledgement of my complaint. I am asking for a specific written answer on whether GEMS will pay Dr Tsebe's outstanding 2026 claims and whether my consultations with Dr Matshoene and the related psychiatric treatment will be funded under my PMB entitlement. This matter concerns continuity of mental-health treatment and access to prescribed care, and it should not be treated as an ordinary generic claims enquiry. Please provide a substantive response addressing each of the above points, including the applicable PMB basis for your decision, rather than simply requesting information that GEMS already has. I expect GEMS to address the actual complaint and provide a clear written outcome. ID is enough *** ,call me ***

URGENT ESCALATION: GEMS FAILURE TO RESPOND TO MEDICATION AUTHORISATION – ONGOING TREATMENT AND PMB CONCERNS

I am lodging this complaint because GEMS has failed to provide me with a substantive response to my previous request concerning the authorisation of my medication.

I previously contacted GEMS and specifically requested:

1. Tegrenol instead of Degranol

The pharmacy has confirmed that Degranol is currently unavailable and is not even available from its supplier. I therefore requested that GEMS urgently authorise Tegrenol as an alternative so that there is no interruption to my treatment.

2. Baclofen

I have already submitted the required Ex Gratia documentation for Baclofen. Despite the documentation having been submitted, I am still waiting for an outcome. I have received no clear decision explaining whether the medication will be authorised or declined.

What is particularly concerning is that I have now followed up with GEMS and have still not received a meaningful response.

This is not simply an administrative query. These medications form part of my ongoing medical treatment, and delays in authorisation directly affect my ability to access the treatment prescribed to me.

I am also concerned because I am already involved in an ongoing dispute with GEMS regarding my PMB registration and access to treatment and medication related to my registered condition. I have repeatedly had to challenge GEMS regarding claims and medication authorisations, and I do not believe that I should have to continuously fight for access to treatment that I am entitled to receive under my benefits.

I therefore require GEMS to provide a substantive written response, not another generic acknowledgement or statement that the matter has been referred to another department.

Specifically, I require GEMS to:

1. Confirm whether Tegrenol will be authorised as an alternative to Degranol, taking into account the pharmacy's confirmation that Degranol is unavailable from both the pharmacy and its supplier.

2. Provide an immediate written outcome regarding my Baclofen Ex Gratia application, including the reasons for the decision if it is declined.

3. Confirm whether these medications are being considered under my applicable PMB benefits, where applicable, and clearly explain the benefit category under which each medication is being assessed.

4. If GEMS refuses or declines either medication, provide the specific clinical, benefit and/or Scheme Rule reasons for the decision rather than simply stating that the medication is not covered.

5. Confirm what steps GEMS is taking to ensure that I do not experience an interruption in my ongoing treatment while the authorisation matter is being resolved.

6. Provide me with the name or department responsible for the outstanding authorisation and a clear timeframe for finalisation.

7. Review my previous correspondence and provide one consolidated response addressing the actual issues I raised.

I want to make it clear that I do not want another generic response advising me to contact the pharmacy, submit documents that I have already submitted, or wait for another department to respond.

GEMS has already been provided with the relevant information and documentation. I am asking for an actual decision, reasons for that decision, and confirmation of the benefit basis on which the decision has been made.

The continued lack of response is unacceptable, particularly where the matter concerns access to prescribed medication and ongoing medical treatment.

I request that this complaint be urgently escalated to a senior official within GEMS and that I receive a substantive written response addressing each of the points above.

Should GEMS maintain that any of these medications are not covered or cannot be authorised, I request that this position be provided to me in writing, together with the reasons and applicable Scheme Rule/benefit provisions, so that I can take the matter further through the appropriate dispute-resolution process.

I expect GEMS to treat this matter with the urgency it deserves.