1 reviews | Active since May 2016
Unlimited in hospital benefits BUT getting bills from service providers
<p>Hi,</p> <p> </p> <p>I am lodging a complaint against GEMS on the above mentioned membership number ********** 47</p> <p>My dad was scheduled to undergo an operation on the 22nd June for hip replacement at the Groenkloof hospital</p> <p>The operation went well however there were complications afterwards where he stayed close to two months at the hospital</p> <p>He was later discharged and transferred to a rehab facility</p> <p> </p> <p>To our surprise we received a couple of bills from the Orthopaedic surgeon, Oncologist and the physiothe******s that attended to him while at the hospital. Based on the option (ONYX) that they are on it shows the benefits are as follows:</p> <p> </p> <p>The first line on the benefit page states “Onyx is a top-of-the-range benefit option that offers extensive cover”. If this is your top of the range package how come it doesn’t pay for the full amount claimed. What does the extensive cover cover?</p> <p> </p> <p>On the benefits prospectus it is also stated that a member will get unlimited benefits in hospital so my question is why are we getting bills now because the member was in the hospital? Why didn’t GEMS pay all bills? Can we get a breakdown and reasons why the whole bill was not paid?</p> <p> </p> <p> </p> <p>For Oncology it is stated that in and out of hospital benefits limit is R414 462 per family. The total bill was and GEMS failed to pay that when we haven’t reached the limit. Can you kindly explain why the bill was not settled</p> <p> </p> <p> </p> <p>For the Orthopaedic surgeon they claimed an amount of R23 628.52 and GEMS only paid R9 350.22. Can we get clarity as to why the medical aid paid a partial amount for the surgery? Please find attached bill from the Orthopaedic surgeon.</p> <p> </p> <p> </p> <p> </p> <p>For Physiotherapy it shows the following on the benefits</p> <p> </p> <p> </p> <p> </p> <p>However we received the attached bill from the Physiothe******s at the hospital totaling R13 000 something. Please see attached invoice</p> <p> </p>
Good day
Thank you for bringing your claim concerns to our attention.
We are looking into this and will provide feedback as soon as possible.
Kind regards
The GEMS online team
Good day
Thank you for bringing your claim concerns to our attention.
We are looking into this and will provide feedback as soon as possible.
Kind regards
The GEMS online team
Good day
Thank you for bringing your concerns about the short payment of your claim to our attention.
We can confirm, that due to the post surgery complications the managed care department has approved all post-operative complications from service date 24 June 2016 as a preferred minimum benefit (PMB).
Because of this we will review all the short paid accounts for all the healthcare service providers who provided services to you between 24 June and 2 August 2016 following the complications you developed.
However, please note that the costs for service providers who charged fees in excess of the Scheme rates for services rendered prior to 24 June 2016, will unfortunately have to be covered by you.
We can however recommend that you apply for financial assistance via the Scheme’s Ex-Gratia process.
Please accept our apologies for the delay in resolving this matter.
Kind regards
The GEMS online team
Good day
Thank you for bringing your concerns about the short payment of your claim to our attention.
We can confirm, that due to the post surgery complications the managed care department has approved all post-operative complications from service date 24 June 2016 as a preferred minimum benefit (PMB).
Because of this we will review all the short paid accounts for all the healthcare service providers who provided services to you between 24 June and 2 August 2016 following the complications you developed.
However, please note that the costs for service providers who charged fees in excess of the Scheme rates for services rendered prior to 24 June 2016, will unfortunately have to be covered by you.
We can however recommend that you apply for financial assistance via the Scheme’s Ex-Gratia process.
Please accept our apologies for the delay in resolving this matter.
Kind regards
The GEMS online team