1 reviews | Active since Aug 2017
GEMS - UNPAID CLAIMS OF R10 000 - EXCEEDING INEFFICIENCY AND POOR COMPLAINT RESOLUTION
<p>I have never, ever come across this level of incompetency across the entire field of claims processing - from the client service centres to the claim processors to the complaints departments and eventually the PRINCIPAL OFFICER to whom all final queries go after all other avenues have been exhausted!!!!</p> <p>GEMS has, through repeated errors in processing, poor interdepartmental communication, and eventually almost non-existent problem resolution "****** R10 000 from me.</p> <p>In October 2016 I sent in several claims for physiotherapy and psychology appointments. These were repeatedly incorrectly processed. After 3 months of repeat phone calls, faxes, emails and visits to client services some of the claims were sorted; however claims amounting to R10 000 were persistently incorrectly processed.</p> <p> By April 2017 and several more phone calls, emails and visits to the service centre I managed to track the ‘comedy of errors’ on GEMS part that had led to the unpaid claims. I then followed the route proscribed by GEMS - "if you have followed all the correct procedures for problem resolution then you may refer your query to the PRINCIPAL OFFICER via email or post".</p> <p>At this point I engaged a lawyer and a lengthy letter - with a clear explanation of the problem and the errors made by GEMS along with all evidence attached - was duly emailed and posted!!!!! at my expense in June 2017. In August 2017 I received an email to say that the psychology account had been approved (they made a mistake and offered to repay dates that had already been paid - in essence they only approved half the claim);</p> <p> <strong>EXCEPT THAT IT WAS REJECTED AS STALE BECAUSE IT HAD NOT BEEN QUERIED </strong><strong>WITHIN 60 DAYS</strong><strong> OF THE CLAIM</strong></p> <p>My lawyer then phoned GEMS to find out why there was no mention of the outstanding physiotherapy claim and why the psychology claim had been rejected as a stale claim.</p> <p><strong>REPLY - WE HAVE NO RECORDS THAT EITHER THE PHYSIO OR THE PSYCHOLOGY ACCOUNT WERE QUERIED SO THEY ARE REJECTED AS STALE AND THERE IS NO RECORD OF ANY LAWYERS CORRESPONDENCE. WE'RE SORRY BUT WE CANNOT HELP YOU FURTHER. PERHAPS YOUR CLIENT COULD SEND US ALL THE REFERENCE NUMBERS OF HER QUERIES </strong></p> <p>I DON'T KNOW WHAT TO DO NEXT. I HAVE EXHAUSTED EVERY PATH INTO GEMS EXCEPT FOR THE OMBUDSMAN AND I FEAR THAT IF I GO TO THE OMBUDSMAN I'M JUST GOING TO GET THE SAME RUN AROUND FROM GEMS.</p> <p> I pay almost R5000 a month in medical aid fees and I have spent hours of valuable time chasing after this. Please can someone advise me WHAT CAN I DO NEXT.</p>