GEMS - poor performance

1. I have been admitted to hospital twice this year with life threatening conditions. I spent numerous days in ICU and High Care. The doctor decided to commence me on Zarelto a bloodthinner. The medical scheme refused to pay for this treatment as according to them it was not used in public hospitals and was thus not the PMB level of care. My doctor however disputed this. 2. I had to pay R960 out of pocket to pay for this medication and app**** to go onto Warfarin and have weekly INR blood tests in order to establish the correct dosage of the medication. This request was already submitted on the 14/09/2023. To date this request has still not been approved (although the scheme's formulary drug of choice) for lifesaving medication and I have run out of my other medication. 3. It has taken several enquiries and submissions, however my physiotherapy accounts in hospital have still not been paid. In spite of me even submitting a scan report, phoning the hospital to add coding (although all my chronic conditions are registered), phoning the case managers, submitting enquiries etc, etc. 4. My in-hospital pathology accounts have not been paid in full, in spite of the fact that even a lay person would be able to establish the need for blood tests done that have been rejected! 5. My hospital account has been short-paid by the scheme for a number of PMB conditions. Yet after numerous requests for an itemised list and reasons for not paying the claim it has not been forthcoming. 6. One of the staff members in the PMB unit have incorrectly indicated that my membership had been terminated. I have however only changed my option. Through this incompetence my request for PMB treatment has further been delayed. I am really disheartened and frustrated by the poor performance of this medical scheme. It appears as if the right hand does not know what the left hand is doing. They NEVER accomplish anything within the turnaround times provided for and very poor communication is experienced even when asked to escalate queries as complaints you never receive any feedback. Once again I will need to go to the pharmacy and pathologist and have to pay out of pocket for services which fall under PMB entitlement due to poor or lack of performance by the medical scheme who was given ample time to approve the treatment. They are more concerned about forms than the patient sitting at the other end of the application without treatment!