GEMS optometry benefits are false

On Monday 27 May 2024 I went to the optometrist. She contacted GEMS to confirm the total benefit available to claim for the eye test with single vision lenses and a frame. GEMS informed her that the Annual family limit available of R5 681 which is limited to R2 963 per beneficiary from which they pay R631.70 for the eye test, R243.50 per lense and R1,564 for the frame. That totals to R2,682.70 and not R2,963. She submitted the claim to GEMS exactly as it was specified to her for R2,682.70 and I have to pay the excess of the claim. I contacted GEMS on 30 May 2024 to find out why they state the member benefit is R2,963 but they only pay R2,682.70. After a 45min call going back and forth with no proper answer, I was informed that the member benefit is indeed R2,963 but they only pay R2,682.70 because that is all that the optometrist claimed for. After a very long explanation that the optometrist only claimed R2,682.70 because they were informed that the medical aid only pays that amount and that I stood next to her when she made the call to confirm the benefit, the consultant at GEMS (Kagiso) told me that rest of the benefit that is left (R280.30) is kept back and carried over to the next year as per scheme rules. I explained clearly that optometry is every 24 months. Even if I go for an eye test next year, I cannot get new lenses if my eye should have deteriorated over 12 months. I can only get lenses every 24 months as per scheme rules; therefore, I need the full member benefit of R2963 which I am entitled to get. Kagiso kept putting me on hold to go speak to his supervisor, only to come back and repeat everything again that the member benefit is R2,963 but the optometrist only claimed R2,682.70 and the rest R280.30 is carried over to the next year. I kept telling him that even if the optometrist claimed the full amount of R2,963 GEMS only pays R2,682.70 with the breakdown of R631.70 for the eye test, R243.50 per lense and R1,564 for the frame. I will still be left with the co-payment because GEMS does not pay the full member benefit as is stipulated in all their documents. I told Kagiso that they must stop lying to the members and clearly state that the member benefit is only R2,682.70. He got upset with me and said they are not lying because the member benefit is R2,963. He even call the optometrist and have me listen to their conversation where he just asked her if GEMS did inform her of the family limit and the member benefit amounts, and that she did submit a claim for only R2,682.70. To there answers she did answer yes, because it is correct. When she asked him what happens to the amount that differs (R280.30) he said it is carried over to the next year and he ended the conversation. After getting back to me, I asked him what he was trying to proof. We are back to where we started. GEMS refuses to pay the optometrist the full member benefit. They ***** money from us in this way because they advertise load and clear the member benefits available, but that is untrue. They keep money back and we lose that money and have to pay that amount in at the service providers as co-payments. We have to pay and pay and pay, just to get less benefits available to us.