PP
Philip P
1 reviews | Active since Apr 2013
24 Jun 2024, 14:10
Avoid Genesis medical scheme (****) at all costs
On 27 April 2024 I dislocated my shoulder. It needed to be relocated under anesthesia. I have a hospital plan with Genesis Med-200 . The basic benefits is any private/public hospital of choice with an amazing 200% rate of cover of scheme rate. I was under the impression that all hospital related bills will be covered. However, Genesis only paid around 75% of my one day in hospital bills of R33 258. They also refuse to provide their scheme tariffs on which they based their medical scheme products. i.e 200% of tariff rate is as meaningless as 500% or 1000% of tariff rates if you dont know what the tariff rate is. Medical schemes tariff rates all differ. I was also informed one the phone on 24 June 2024 that the reason they did not pay the emergency fee is because it took 1 hour to get me in the theatre from the time I was admitted to hospital. This medical scheme is more a medical **** and should be avoided at all costs. Fortunately 25% of R33285 is manageable. However, I do not want to pay 25% of a R1 or 2 million bill one day. I am warning all prospective and current clients that you take on massive risk with Genesis medical aid. Disclosure of Scheme tariffs should be made compulsory to all medical aid schemes ( how else can you compare products?). The scheme ( or is it "****"?) also find all sorts of loopholes not to pay. ie. for being admitted to surgery one hour after hospital admittance.
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Replies (2)
Genesis Medical Scheme's replyOfficial
24 Jun 2024, 15:02Dear Mr Prinsloo
It is a pity that you have not read our email to you, as we tried our best to explain to you. We will however and for the sake of people who may read your review, share some information with you which may assist you in understanding the funding model of medical schemes in South Africa. We will specifically comment on the 16 open medical schemes in SA, as that is the landscape in which we operate.
The 16 open medical schemes in SA offer some 113 benefit options - most of these benefit options have a scheme rate of 100%. There are some benefit options that have a scheme rate of 200% and only three benefit options have a scheme rate of 300%. These three options are the “top” benefit options on three of the open medical schemes, where monthly contributions for an adult main member range between R10,303 and R14,883 per month.
It is simply impossible for any medical scheme in SA to send / publish their scheme rates on the tens and tens and tens of thousands of medical aid tariff codes used by medical schemes and healthcare providers. Most of these codes are specific for each healthcare profession, meaning that general practitioners would have a set of unique codes, as does a physiothe****** or dentist, etc. If of any help, the billing rules for tariffs can be viewed in the 2024 SAMA Electronic Medical Doctors' Coding Manual - https://www.samedical.org/products/readMore/1
There is also nothing ******* (as you have alleged) in the scheme rates of any medical scheme in SA. A scheme rate / tariff refers to the fees / rates that a medical scheme will cover in respect of the tariff codes being billed. These rates are therefore approximately 100% of what was previously known as the “medical aid rate”, or 200% or 300% thereof. In your specific instance, it will be listed under the “Benefit Amount” that appears on your monthly statement. This is the scheme rate that you have requested and we are not mysterious about our rate of cover - it is clearly displayed on your statement.
When doctors or other service providers charge more than e.g. 200% of the scheme rate (referring to your Genesis benefit option), then the member will have co-payments when treatment was received in a private hospital / non-DSP. It is also for this reason that people take out gap cover, as service providers often charge more than the 100% or 200% (or 300%) cover that their medical schemes provide. A medical scheme’s rate of 100% (for example) does not, in the South African context, mean that 100% (“everything”) of all costs will be covered - it simply means that the scheme will reimburse the cost at 100% of their scheme rate. It is also not misleading marketing, as it is general accepted practice to communicate benefits in this way. To this end, the Council for Medical Scheme approves this wording / statement of benefits / brochures before a scheme can market and sell its products. The big problem is that many consumers don’t understand the benefit structures of medical schemes - and that does not make a medical scheme guilty of ******* practices, as you refer to it.
The emergency fees, in your instance, have been declined for funding, as it did not meet the criteria of a “medical emergency”. An emergency medical condition means the sudden and, at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. It is important to remember that the condition must require “immediate” life-saving treatment and not “urgent” treatment, like in your case.
We know this may not be the feedback that you were hoping for, but we have tried our best to explain our rates (for both Genesis and the industry in general) to you in a way that will make sense.
Yours sincerely
GENESIS MEDICAL SCHEME
GENESIS MEDICAL SCHEME
Genesis Medical Scheme's reply24 Jun 2024, 15:02
Official
Dear Mr Prinsloo
It is a pity that you have not read our email to you, as we tried our best to explain to you. We will however and for the sake of people who may read your review, share some information with you which may assist you in understanding the funding model of medical schemes in South Africa. We will specifically comment on the 16 open medical schemes in SA, as that is the landscape in which we operate.
The 16 open medical schemes in SA offer some 113 benefit options - most of these benefit options have a scheme rate of 100%. There are some benefit options that have a scheme rate of 200% and only three benefit options have a scheme rate of 300%. These three options are the “top” benefit options on three of the open medical schemes, where monthly contributions for an adult main member range between R10,303 and R14,883 per month.
It is simply impossible for any medical scheme in SA to send / publish their scheme rates on the tens and tens and tens of thousands of medical aid tariff codes used by medical schemes and healthcare providers. Most of these codes are specific for each healthcare profession, meaning that general practitioners would have a set of unique codes, as does a physiothe****** or dentist, etc. If of any help, the billing rules for tariffs can be viewed in the 2024 SAMA Electronic Medical Doctors' Coding Manual - https://www.samedical.org/products/readMore/1
There is also nothing ******* (as you have alleged) in the scheme rates of any medical scheme in SA. A scheme rate / tariff refers to the fees / rates that a medical scheme will cover in respect of the tariff codes being billed. These rates are therefore approximately 100% of what was previously known as the “medical aid rate”, or 200% or 300% thereof. In your specific instance, it will be listed under the “Benefit Amount” that appears on your monthly statement. This is the scheme rate that you have requested and we are not mysterious about our rate of cover - it is clearly displayed on your statement.
When doctors or other service providers charge more than e.g. 200% of the scheme rate (referring to your Genesis benefit option), then the member will have co-payments when treatment was received in a private hospital / non-DSP. It is also for this reason that people take out gap cover, as service providers often charge more than the 100% or 200% (or 300%) cover that their medical schemes provide. A medical scheme’s rate of 100% (for example) does not, in the South African context, mean that 100% (“everything”) of all costs will be covered - it simply means that the scheme will reimburse the cost at 100% of their scheme rate. It is also not misleading marketing, as it is general accepted practice to communicate benefits in this way. To this end, the Council for Medical Scheme approves this wording / statement of benefits / brochures before a scheme can market and sell its products. The big problem is that many consumers don’t understand the benefit structures of medical schemes - and that does not make a medical scheme guilty of ******* practices, as you refer to it.
The emergency fees, in your instance, have been declined for funding, as it did not meet the criteria of a “medical emergency”. An emergency medical condition means the sudden and, at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. It is important to remember that the condition must require “immediate” life-saving treatment and not “urgent” treatment, like in your case.
We know this may not be the feedback that you were hoping for, but we have tried our best to explain our rates (for both Genesis and the industry in general) to you in a way that will make sense.
Yours sincerely
GENESIS MEDICAL SCHEME
GENESIS MEDICAL SCHEME
PP
Philip P's updateReviewer Update
24 Jun 2024, 17:38Its a pity I received Genesis email at 14h42, while the hellopeter complaint was posted at 14h10. But somehow I was supposed to first read their response? From the response it is clear that Genesis sees no mystery in scheme tariffs. According to Genesis the scheme tariff will be disclosed with the account statement. How reassuring to know what the scheme is willing to pay after receiving the bill. They are not willing to publish their tariff scheme rates since the list is "too long" but then refer me to a link with price guidelines . Why is the list too long for Genesis but not for SAmedical? Genesis sees nothing ********* or misleading in not publishing their tariff rates on which their marketing is based since ... wait for it.... its common acceptable practice. My dislocated shoulder was not deemed an emergency since only having use of one arm and being in serious pain is not an emergency for Genesis. All prospective and current clients please take note! Rather use medical aid schemes with network service providers where payment is guaranteed. To Genesis clients, when you need emergency care while in excruciating pain. Relax , and start searching for doctors willing to accept Genesis tariff fees. You wont know what the fees are (the list is too long) but hopefully the doctors/specialists will, that is if you can find one orthopedic surgeon that is not asking 4 times what Genesis is willing to pay. Genesis please provide me with one orthopedic surgeon's name that works on your tariff rate in the Cape Metro.
PP
Philip P's update24 Jun 2024, 17:38
Reviewer Update
Its a pity I received Genesis email at 14h42, while the hellopeter complaint was posted at 14h10. But somehow I was supposed to first read their response? From the response it is clear that Genesis sees no mystery in scheme tariffs. According to Genesis the scheme tariff will be disclosed with the account statement. How reassuring to know what the scheme is willing to pay after receiving the bill. They are not willing to publish their tariff scheme rates since the list is "too long" but then refer me to a link with price guidelines . Why is the list too long for Genesis but not for SAmedical? Genesis sees nothing ********* or misleading in not publishing their tariff rates on which their marketing is based since ... wait for it.... its common acceptable practice. My dislocated shoulder was not deemed an emergency since only having use of one arm and being in serious pain is not an emergency for Genesis. All prospective and current clients please take note! Rather use medical aid schemes with network service providers where payment is guaranteed. To Genesis clients, when you need emergency care while in excruciating pain. Relax , and start searching for doctors willing to accept Genesis tariff fees. You wont know what the fees are (the list is too long) but hopefully the doctors/specialists will, that is if you can find one orthopedic surgeon that is not asking 4 times what Genesis is willing to pay. Genesis please provide me with one orthopedic surgeon's name that works on your tariff rate in the Cape Metro.