GEMS Declining Funding for Emergency C-Section – R10 016 Co-Payment Dispute

My gynaecologist Dr Nthabiseng Borotho booked that I be induced.

On the 30th of November I was then admitted. The induction process began as soon as I was admitted and after 2 failed inductions and extremely hard contractions, on the 1st December around past 10pm the induction was said to have failed and the doctor decided on an emergency c-section which happened in the early hours of the 2nd December around midnight since my daughter was born at 00:46.

The beginning of January I received a call from Lenmed hospital Randfontein, the hospital I was admitted at, being told that I have to pay a co-payment of R10 016 because my gynaecologist did not submit a template motivating why I had to have a c-section. Therefore my medical aid did not pay them this amount. I called my gynaecologist and the personal assistant told me that the template was submitted, that she even has a copy and can resend. She told me to ignore this.

I ignored as instructed and recieve a call again days later regarding this. I called the gynaecologist again and she assures me that she will send the documents again so that this is processed.

On the 22 January, I went to my gynaecologist offices to ask how things are progressing regarding this. I then get sent to the case manager Elizabeth at Lenmed hospital Randfontein to go enquire. Elizabeth mentions that she sent my documents for reprocessing on the 16th January and that I should call GEMS to enquire on how that process is going.

I then recieve a call again. This time the lady I speak to finally acknowledges that my documents were submitted, they were all complete but my medical aid GEMS does not want to make a payment because it apparently does not see how my case was an emergency and there's a certain CTG being requested by the person handling things at GEMS that can't be provided because I was already at the table at that time of the requested CTG. My gynaecologist and the hospital apparently motivated to no avail and now I'm required to pay this money.

I call GEMS to ask what to do in this instance I get told that my template does not meet the funding criteria and that my gynaecologist has to do a new template that meets the requirement so that the co-payment can be lifted.

On the 19th February, I go to my Gynaecologist. She mentions that the template does meet the requirements. She mentions how she does not understand how it does not because she wrote exactly what had happened and any doctor would know that my situation required an emergency c-section. She persuaded me to call GEMS again and try sort this out on my end.

This was not an elective c-section from my side because I know according to the terms and conditions of GEMS, I would have had to pay for an elective c-section. I am so frustrated because I have no idea where that sort of money will even come from. I have a new baby and added debts of my own as it and I know even with a payment plan this would be a struggle for me to pay.

I need assistance to sort this out because I have been calling GEMS and as I recieve calls and texts I am getting more and more frustrated and stressed which is the most dangerous feeling for one to feel postpartum.

I do not even know what to do anymore.