Shocking Member service!!

We have received the worst service possible from GEMS! I would have rated with a ZERO star rating but I would not be able to post my complaint without giving this at least a ONE. Service definitely isn't worth the 1 star at all.

My account (dependent) for occupational the****** dated 07.09.2017 not settled as it was not claimable under the authorization number provided. The procedure however was for the operation I underwent on the same date. It was for a splint/cast that was to be made for my hand that was just operated on and was imperative for my recovery.

When I received my GEMS statement 09 October 2017, I immediately queried the above matter with your call centre Ref MH ********** 9. The agent however very unprofessionally proceeded to "explain" to my wife using ridiculous references why the account was not paid. He explained so that she could better "understand" the non payment, it was as if I went into hospital for a hand operation and then had dental surgery done while in hospital and the dentist tried to claim for it under the same authorization code.

This Consultant also informed me that the Occupational The****** needed to send a motivation for this account to ********** & ********** for the matter to be escalated. I advised the Occupational The****** of this and the motivation was sent to GEMS on 13 October 2017. I called GEMS a few days later and was advised that the motivation was sent to the incorrect place but that they managed to locate it and refer it to the correct department and that it would take 5 days to be processed.

On 27 October I followed up with Gems and was advised that the matter had just been received and that it would be escalated to the correct department (Reference number for the call I didn't note as I was on hold for 30+mins).

On Friday 03 November 2017 I spoke to Loraine Louw Ref MH ********** 3 who kept me on the line for over 40 mins but had promised to escalate the matter yet again and give me a call back with feedback from her supervisor Nomsa Hlati. At 16h01 she called me back notifying me that there is no feedback as yet and that she would call me back on Monday 06 November which she did not adhere to. I was also referred to the Authorization department's Elizabeth Skosana who gave me the run around yet again.

On the 7 November I was on the line for over 40mins yet again which seems to be standard practice for your call centre. I spoke to Ntetwa Thengwa Ref MH ********** 6. She went to consult her team leader and after being on hold for almost 30mins, I put the phone down as I had other commitments. When I got home I called GEMS yet again and unfortunately didn't get the agents name or reference number for the call but she was calling the team leader and after 40mins the call from your side went dead.

While being on hold (on my Landline) in the above call I called GEMS from my cellphone and the first agent ended the call almost immediately. I then called again and spoke to Brian Thlomelang Ref MH ********** 4 he said that he could not trace the names or reference numbers for my two previous calls as no notes were made on the system. He also said that he would escalate the matter to his team leader Primrose Hlophe but was unable to put me through to her as she had already left. I asked if I could be referred to any other team leaders/managers but was told that as it was almost 17h00 that they had all already left work. He promised that Primrose would give me a call by 09h30 tomorrow morning to resolve the matter. No resolution or valuable feedback was provided.

It was mentioned that your system indicates that this matter has been escalated 7 times already and that is excluding that which was promised to be escalated on the 7th November. I am highly disgruntled and frustrated in the way in which GEMS handles their clients and although I understand that certain procedures need to be followed, there is a line which was crossed in this case. I am also quite disturbed as I have read online, discussed with my colleagues and checked on Hello Peter that this is a common practice by GEMS.

I have again today called to query feedback on the outstanding payment and I spoke to Francois - Ref MH ********** 9 who advised that he could see that the claim was being handled but says that the PMB review department could take a few months to return with an answer.

I have GAP cover because I know that GEMS short pays on almost every possible occasion and I have come to terms with this but I cannot claim more than once (for the same procedure) from my GAP cover. I also have a 3 month window in which I need to submit my claim to GAP cover... it is roughly 14 days and my 3 month window will be expired.

I also have the service provider wanting payment and I am unable to provide any feedback as GEMS has been keeping us in the dark for the better part of 2 months!

This exact complaint was sent to GEMS on the 7th via email and to date we have not received any feedback!

We pay so much money on a monthly basis for medical aid only to have them (consistently) short pay claims, give clients the run-around and provide shocking client service. This methodology basically forces members to pay their own bills, although these should initially be covered by my medical aid.

I trust that this matter will be resolved with urgency as it has almost been 2 months since the motivation was sent. I await your response.