GEMS REFUSE TO PAY OUT MY 6 MONTH OLD CLAIM DESPITE GIVING AUTHORISATION FOR PROCEDURE

<p>Member nr ********** 68 Onyx plan.</p> <p> </p> <p>I have undergone a back operation in January 2016, and obtained preauthorisation from GEMS for the procedure. This means that they were aware of what the whole procedure entailed. They said that I would have to pay for the scope, which I did. I also had to more than R3500.00 for consultations for the same doctor during that period, out of my own pocket.</p> <p> </p> <p>After receiving an account from the surgeon in April, I made enquiries as to why the account has not been settled as yet. They advised that they required a motivation letter from the doctor. The doctor submitted same immediately.</p> <p> </p> <p>It is now six months after the procedure, and yet still the account has not been settled. I have made more than 15 phone calls to GEMS (17/4 Rose, 19/4 Martha & Ashley, 24/6 Natalie & Ashley, 29/6 Adelaide, 5/7 Nicolene, 7/7 Martha & Avica, 8/7 Martha, 12/7 Cheslyn, 13/7 Vivica & Cheslyn, and everytime just get the same story that it is with the medical advisor, and that it can take between 48 hours to 5 days to finalize it.</p> <p>Nicolene confirmed that the motivation letter comp**** to all the queries on the different codes raised, so WHAT MORE DO YOU NEED TO FINALIZE THIS CLAIM?</p> <p> </p> <p>I am now on a daily basis on the phone with them, and still just get the story that it is with the medical advisor and they will speak to the teamleader about it. Meanwhile, the doctor is threatening to institute legal action against me for almost R50,000.00! I have told the consultants that my next call is to the Ombudsman for Medical Schemes, which WILL be my next action should this complaint not be addressed.</p> <p> </p> <p>I need clarity WHEN this claim will be settled.</p> <p> </p> <p>On another note, I can’t even seem to get authorisation for a crown, and did the dentist already app**** for it in the first week of June!</p> <p> </p> <p>WHAT IS HAPPENING TO GEMS? IS THE BOAT STARTING TO SINK?? AND WHERE DOES IT LEAVE US – WHO WERE FORCED TO JOIN GEMS???</p> <p> </p>