1 reviews | Active since Feb 2013
CLAIM REJECTION WITH NO PLAUSIBLE REASON
We have a Genesis Medical Scheme - Med-200 for almost 6 years. It is a hospital plan with no day to day savings but the scheme does cover a few items out of hospital. My claim for plus/minus R3300 was rejected for reasons unbeknown to me as the statement I received from them says Code 19 - Code 19 means = Member Liable for Payment. Member Liable for Payment is not a valid reason . This is NOT a reason for non-payment and I would like a valid reason. When I initially made an application for membership I disclosed skin conditions and I was under the impression these would be covered by the scheme as I received a letter from them saying this would so, and most importantly the pre cancerous lesions on my person that needed liquid nitrogen were not covered or paid for.
In terms of the Scheme Rules, specifically Annexure C, rule 28, the excision and/or cautery and/or cryotherapy and/or any other form of treatment of all skin and subcutaneous lesions, both in and out of hospital and irrespective of the type of anesthesia required, including but not restricted to naevi, warts, keratosis, skin tags, sebaceous and other cysts, papillomas, birthmarks, hemangiomata, lipomas, etc. is a Scheme EXCLUSION.
In other words, the cost of the above is not paid for by the Scheme, UNLESS it is shown on histology that the lesion that has been removed is malignant (cancerous). If this was the case, then Genesis would have covered the cost of the above procedure in accordance with the Rules of the Scheme, i.e. your cancer benefit.
Fortunately, we have had no confirmation of the presence of any malignancy that require further treatment under your cancer benefit and for this reason, the cost of the procedure, being a Scheme exclusion, will be for your own account (rejection code 19).
We trust that this feedback will answer your question.
Yours sincerely
GENESIS MEDICAL SCHEME
In terms of the Scheme Rules, specifically Annexure C, rule 28, the excision and/or cautery and/or cryotherapy and/or any other form of treatment of all skin and subcutaneous lesions, both in and out of hospital and irrespective of the type of anesthesia required, including but not restricted to naevi, warts, keratosis, skin tags, sebaceous and other cysts, papillomas, birthmarks, hemangiomata, lipomas, etc. is a Scheme EXCLUSION.
In other words, the cost of the above is not paid for by the Scheme, UNLESS it is shown on histology that the lesion that has been removed is malignant (cancerous). If this was the case, then Genesis would have covered the cost of the above procedure in accordance with the Rules of the Scheme, i.e. your cancer benefit.
Fortunately, we have had no confirmation of the presence of any malignancy that require further treatment under your cancer benefit and for this reason, the cost of the procedure, being a Scheme exclusion, will be for your own account (rejection code 19).
We trust that this feedback will answer your question.
Yours sincerely
GENESIS MEDICAL SCHEME