GEMS DECLINED TO GRANT AUTHORISATION FOR EMERGENCY CONSULTATION AT CASUALTY

On Wednesday, 01 April 2026, at 17h57, my daughter was rushed to Mediclinic ER as it was after business hours. The hospital is on our network. As instructed by the hospital, I called and emailed GEMS within 24 hours at 08h00 on Thursday, 02 April 2026, to get authorisation for the visit.

On 7 April 2026, GEMS paid for the hospital, and not the attending doctor in the emergency room. This doesn't make sense as they paid for the walls and not the person who treated the child. In more than 4 years that my child has been covered with GEMS, this was probably her 3rd or 4th claim with GEMS. When I went to Dischem to buy her medication (antibiotics, ointments, and pain medication), they were declined as they are not on the GEMS formulary. Who doesn't pay for antibiotics for a sick person and panado for a child? The meds amounted to R1300. I pay R6133 to GEMS every month for me and my two kids.

Further, I have been on the Disease Management Programme for 10+ years. Last year, GEMS stopped funding my Plenish K without a workable alternative. I have been taking this pill for many years. Somehow, they decided they would not pay despite the motivation submitted by my cardiologist. I received an email this week stating I’ve “defaulted” on chronic medication — I haven’t taken it this year because GEMS won’t cover it.

At R6,133 p/m, GEMS functions as a hospital-only cover rather than a comprehensive medical aid. The formulary and authorisation process fail members during emergencies. I am requesting urgent review and reversal of these rejections. This is despite the medical aid that we cannot afford; now we have to pay doctors' fees and medication out of pocket. I do not have the money to pay for that visit. The doctor is likely going to list me at the credit bureaus.