CD
Carmen D
1 reviews | Active since Aug 2026
04 Sept 2026, 12:35
GEMS Has Finally Reached Out, But Two Years of Frustration Cannot Be Ignored
I want to provide an update to my previous complaint. GEMS has since contacted me by telephone and advised that my case will be investigated and that they will get back to me. I appreciate that someone has finally reached out, but this does not mean that my complaint has been resolved. I have been trying to get this matter sorted out for two years. Two years of trying to obtain answers, dealing with the uncer*****y surrounding the R10,000 co-payment, and feeling as though I have to keep pushing just to get my medical aid to properly engage with me. I understand that the investigation may take time and that it has not yet been seven days. However, I do not believe that I should have to wait another seven days simply to receive reassurance that my case is being attended to. After everything I have already been through, a follow-up call to reassure me that my matter is being actively investigated would be the least I could expect. I am a paying client. I have trusted GEMS with my healthcare needs, and I deserve to feel that my concerns are being taken seriously. I should not have to repeatedly complain on HelloPeter just to be heard. I am not asking for an unreasonable demand. I am asking for proper communication, accountability, and a genuine effort to resolve a matter that has been ongoing for far too long. GEMS, I appreciate the call, but I need more than an acknowledgement. I need to see that this matter is being taken seriously, and I need to be kept informed while the investigation is underway. I will continue to document my experience until this matter is properly resolved. Two years is long enough. I deserve better as a paying client.
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Replies (4)0
Replies (4)
Gems (Government Employees Medical Scheme)'s replyOfficial
04 Sept 2026, 13:05Good day,
Thank you for engaging with us. We are following your message, and feedback will be provided. If you have an urgent query, please contact us on ***(members Toll-free number) & ***(providers).
Call Centre Hours: Monday - Friday: 8h00 - 17h00 & Saturday: 8h00 - 12h00.
Emergency number: ***(available 24 hours)
If you wish to submit a compliment, please email us on at ***.
We look forward to receiving your positive feedback.
Regards, GEMS
Gems (Government Employees Medical Scheme)'s reply04 Sept 2026, 13:05
Official
Good day,
Thank you for engaging with us. We are following your message, and feedback will be provided. If you have an urgent query, please contact us on ***(members Toll-free number) & ***(providers).
Call Centre Hours: Monday - Friday: 8h00 - 17h00 & Saturday: 8h00 - 12h00.
Emergency number: ***(available 24 hours)
If you wish to submit a compliment, please email us on at ***.
We look forward to receiving your positive feedback.
Regards, GEMS
CD
Carmen D's updateReviewer Update
04 Sept 2026, 13:14I have received this generic response before
CD
Carmen D's update04 Sept 2026, 13:14
Reviewer Update
I have received this generic response before
CD
I have now received GEMS’ written response to my complaint, and I am extremely disappointed with the outcome.
Carmen D's updateReviewer Update
09 Sept 2026, 12:13I have now received GEMS’ written response to my complaint, and I am extremely disappointed with the outcome.
GEMS has confirmed that my R10,000 co-payment was waived on 13 June 2025. Their letter states that the outstanding clinical information, including the partogram, was received and reviewed, and that the waiver was approved.
So I need to ask a very simple question:
If the co-payment was waived, why am I still being left out of pocket?
GEMS has now confirmed that the claim was originally short-paid because of the co-payment. They have also confirmed that the co-payment was subsequently waived. Yet I am still being told that the claim cannot be reprocessed because of the stale-claim process.
I understand that there are rules and procedures. But I am the member who has been trying to resolve this matter for two years, and I should not have to carry the financial consequences of an administrative process that I did not create.
What is particularly frustrating is that GEMS’ own letter acknowledges that the claim “could potentially qualify for reprocessing” following the waiver. However, instead of resolving the matter, I am now being told that the required follow-ups were not provided.
I want GEMS to explain why the waiver they approved is not being honoured through payment of the claim.
I also want to know why I am being expected to resolve a matter that has been ongoing since 2024, when I have repeatedly contacted GEMS and the hospital to try to get answers.
I trusted GEMS with my healthcare needs. I trusted that when a co-payment was waived, that decision would mean something. I did not expect to spend two years trying to get a medical aid to honour its own decision.
I appreciate that GEMS has finally investigated my complaint and provided a written response. But this is not a resolution. It is an explanation of why I am still waiting.
I am asking GEMS to urgently review this matter again, specifically in light of the confirmed waiver, and provide a clear written explanation of why the claim has not been paid.
I also expect GEMS to explain what steps it is taking to resolve the outstanding issue with the provider, rather than simply leaving me to continue chasing the matter.
I am a paying client. I deserve more than being passed between departments and being told to wait. I deserve a medical aid that takes responsibility for its decisions and assists me in resolving a matter that has already taken far too long.
Two years is long enough. I want GEMS to hear me, see me, and properly resolve this matter.
CD
Carmen D's update09 Sept 2026, 12:13
Reviewer Update
I have now received GEMS’ written response to my complaint, and I am extremely disappointed with the outcome.
GEMS has confirmed that my R10,000 co-payment was waived on 13 June 2025. Their letter states that the outstanding clinical information, including the partogram, was received and reviewed, and that the waiver was approved.
So I need to ask a very simple question:
If the co-payment was waived, why am I still being left out of pocket?
GEMS has now confirmed that the claim was originally short-paid because of the co-payment. They have also confirmed that the co-payment was subsequently waived. Yet I am still being told that the claim cannot be reprocessed because of the stale-claim process.
I understand that there are rules and procedures. But I am the member who has been trying to resolve this matter for two years, and I should not have to carry the financial consequences of an administrative process that I did not create.
What is particularly frustrating is that GEMS’ own letter acknowledges that the claim “could potentially qualify for reprocessing” following the waiver. However, instead of resolving the matter, I am now being told that the required follow-ups were not provided.
I want GEMS to explain why the waiver they approved is not being honoured through payment of the claim.
I also want to know why I am being expected to resolve a matter that has been ongoing since 2024, when I have repeatedly contacted GEMS and the hospital to try to get answers.
I trusted GEMS with my healthcare needs. I trusted that when a co-payment was waived, that decision would mean something. I did not expect to spend two years trying to get a medical aid to honour its own decision.
I appreciate that GEMS has finally investigated my complaint and provided a written response. But this is not a resolution. It is an explanation of why I am still waiting.
I am asking GEMS to urgently review this matter again, specifically in light of the confirmed waiver, and provide a clear written explanation of why the claim has not been paid.
I also expect GEMS to explain what steps it is taking to resolve the outstanding issue with the provider, rather than simply leaving me to continue chasing the matter.
I am a paying client. I deserve more than being passed between departments and being told to wait. I deserve a medical aid that takes responsibility for its decisions and assists me in resolving a matter that has already taken far too long.
Two years is long enough. I want GEMS to hear me, see me, and properly resolve this matter.
CD
Carmen D's updateReviewer Update
11 Sept 2026, 10:57GEMS: The 60-Day Rule – Are Members Actually Being Told About This?
I am writing this update because I believe other GEMS members need to know about this.
After two years of trying to resolve my medical claim, GEMS has now explained that my claim cannot be reprocessed because the required follow-ups were not made within their 30/60-day process.
Here is the part that I find extremely problematic:
I was never (through any form of correspondence) told that I, as the member, had 60 days to follow up on a short-paid claim or that failing to do so could ultimately prevent the claim from being reprocessed.
In my case, the hospital was waiting for additional clinical information from the treating doctor. The hospital has explained that this was the reason for the delay. Yet GEMS is now saying that there should have been follow-ups within the prescribed timeframe.
But where was the communication to me, the member, saying:
“Your claim is short-paid. Additional information is outstanding. You have 60 days to ensure that this is followed up, otherwise your claim may become stale and may not be reprocessed.”
I did not receive that warning.
And this is what I believe members need to question.
GEMS refers to this as part of its Scheme rules and stale-claim process. I understand that medical schemes have rules and that members are bound by their registered Scheme Rules. GEMS itself states that its rules contain important information that members should know.
But having a rule available somewhere is not the same as making a member actively aware that the rule is about to affect them. Oh a call center agent said to me "No we do not send you correspondence that you have 60 days to follow up on the claim, we tell you this when you phone our call center to query the rejected claim"
When a member is told that there is a shortfall because information is outstanding from the treating doctor, the reasonable expectation is that the member will be told what they need to do, what the deadline is, and what the consequences will be if the matter is not resolved.
Instead, I have spent two years trying to resolve this matter and am now being penalised because, according to GEMS, the required follow-ups were not made within their 30/60-day timeframe.
How is a member supposed to know that they need to do this if nobody tells them?
I would genuinely like GEMS to answer this question:
At what point was I, the member, clearly informed that I had 60 days to follow up on this particular shortfall and that failure to do so could prevent the claim from ever being reprocessed?
I am not saying that GEMS is not entitled to have Scheme rules. I am questioning how those rules are communicated to members and whether members are given meaningful notice when those rules are directly going to affect their claims.
I also want other GEMS members to be aware of this. If your claim is short-paid or additional information is outstanding, do not assume that the hospital or doctor is handling everything. Ask GEMS specifically whether there is a 30/60-day deadline, what you personally need to do, and what happens if the information is not received in time.
Because I certainly did not understand that this was my responsibility and now I am the one facing the consequences.
GEMS, I stand to be corrected: please show me where and how members are clearly informed of this specific requirement when a claim is short-paid and additional clinical information is outstanding.
I am asking because I genuinely believe members deserve to know.
CD
Carmen D's update11 Sept 2026, 10:57
Reviewer Update
GEMS: The 60-Day Rule – Are Members Actually Being Told About This?
I am writing this update because I believe other GEMS members need to know about this.
After two years of trying to resolve my medical claim, GEMS has now explained that my claim cannot be reprocessed because the required follow-ups were not made within their 30/60-day process.
Here is the part that I find extremely problematic:
I was never (through any form of correspondence) told that I, as the member, had 60 days to follow up on a short-paid claim or that failing to do so could ultimately prevent the claim from being reprocessed.
In my case, the hospital was waiting for additional clinical information from the treating doctor. The hospital has explained that this was the reason for the delay. Yet GEMS is now saying that there should have been follow-ups within the prescribed timeframe.
But where was the communication to me, the member, saying:
“Your claim is short-paid. Additional information is outstanding. You have 60 days to ensure that this is followed up, otherwise your claim may become stale and may not be reprocessed.”
I did not receive that warning.
And this is what I believe members need to question.
GEMS refers to this as part of its Scheme rules and stale-claim process. I understand that medical schemes have rules and that members are bound by their registered Scheme Rules. GEMS itself states that its rules contain important information that members should know.
But having a rule available somewhere is not the same as making a member actively aware that the rule is about to affect them. Oh a call center agent said to me "No we do not send you correspondence that you have 60 days to follow up on the claim, we tell you this when you phone our call center to query the rejected claim"
When a member is told that there is a shortfall because information is outstanding from the treating doctor, the reasonable expectation is that the member will be told what they need to do, what the deadline is, and what the consequences will be if the matter is not resolved.
Instead, I have spent two years trying to resolve this matter and am now being penalised because, according to GEMS, the required follow-ups were not made within their 30/60-day timeframe.
How is a member supposed to know that they need to do this if nobody tells them?
I would genuinely like GEMS to answer this question:
At what point was I, the member, clearly informed that I had 60 days to follow up on this particular shortfall and that failure to do so could prevent the claim from ever being reprocessed?
I am not saying that GEMS is not entitled to have Scheme rules. I am questioning how those rules are communicated to members and whether members are given meaningful notice when those rules are directly going to affect their claims.
I also want other GEMS members to be aware of this. If your claim is short-paid or additional information is outstanding, do not assume that the hospital or doctor is handling everything. Ask GEMS specifically whether there is a 30/60-day deadline, what you personally need to do, and what happens if the information is not received in time.
Because I certainly did not understand that this was my responsibility and now I am the one facing the consequences.
GEMS, I stand to be corrected: please show me where and how members are clearly informed of this specific requirement when a claim is short-paid and additional clinical information is outstanding.
I am asking because I genuinely believe members deserve to know.