Genesis is shocking!

Item: Genesis Medical Scheme
Rating: 1
Author: Natalie S

I was diagnosed with breast cancer at the end of 2018. Genesis has been shocking throughout my entire journey. It started with my first surgery, which was a double mastectomy with reconstruction, I chose to have both breasts removed as I was young and had a family history of BC. They would only offer a contribution towards the surgery. They forced us into signing a document accepting the contribution, otherwise they would not give us a hospital authorization number. This put all liability on us if there were any complications in hospital, which was a 5 day stay. They refused to pay for any reconstruction as they believe you must live the rest of your life with a flat chest, like I had some sort of choice in all of this. The reconstruction is a 2 part surgery, the first one they put expanders in to slowly fill over a period of time in order to slowly stretch the muscle. Then after a long period of time you go back for a second surgery to swop the expanders for a prosthesis. The second surgery cost R85000 alone which they contribute nothing to. They also refused to pay for a drug I needed for my specific Cancer, which cost R13000 every 3 weeks. They refuse to pay for my port removal as I wanted to have it removed during my reconstruction, so as not to have to go under general twice. Their rule is they don’t pay for anything that is done in conjunction with something the don’t cover(reconstruction). We have recently found out that they have also rejected a number of claims for chemo transfusions and we have been sent final demands for these payments. The whole experience has been awful but what has been even worse is the fact that we have had to bankrupt ourselves in order to keep me alive. Not once through this entire process has Genesis ever phoned me and spoken to me about my diagnosis. Genesis DO NOT, under any circumstances, do what is in the best interest of their members. Yes other medical aids are difficult too but throughout this process I have spoken to many, many women who are going through this and none of them have been through the same fight with their medical aids that I have. It will take us years to come back from this financial loss. Cancer is life and death, I want to do anything I can to save other people from going through this financial and emotional trauma.

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Genesis Medical Scheme's replyOfficial

25 Jun 2019, 07:48

Dear Natalie It is really a pity that you feel Genesis has not supported you throughout your journey of breast cancer. We would prefer not to comment and share your personal information on a public platform and we will therefore restrict our reply. Regrettably what you have stated is neither true nor factually correct. We invited your husband, the principal member of the Scheme, to meet with us and to discuss your concerns. He has declined the invitation. As a medical scheme, we do not make cold hearted decisions about the well-being of our members. At the time, there was no evidence presented to the Scheme of a prior family history of breast cancer, nor was any other clinical information presented in support of the Scheme funding a prophylactic mastectomy of the unaffected breast. The Medical Schemes Act is very clear in its ambit on what must be funded as a Prescribed Minimum Benefit (PMB) in the event of breast cancer. There are any number of factors that must be considered before a member qualifies for prophylactic mastectomy as PMB level of care in Public hospitals – the standard by which medical schemes are judged when it comes to PMB conditions. On the evidence provided to us, you do not qualify for the Scheme to pay, either for the prophylactic treatment of for the very expensive biologic drug you sought to use. As you rightfully mentioned, the election to have a double mastectomy and to remove the disease-free breast as well (including the costs associated with this), was your personal choice and the members of Genesis can hardly be expected to pay for this personal choice made by you. It is just simply not true that we only offered a contribution towards the mastectomy of the affected breast and that we “refused” to pay for the reconstruction of that breast. The Scheme’s offer, which your husband did not sign under duress, specifically stated that the Scheme’s funding offer was inclusive of both the mastectomy and the reconstruction of the affected breast. The amount offered and accepted by your husband was almost five times the cost of such treatment in a Public hospital and was based on the Scheme’s past claims experience for such procedures. Whilst we understand that cancer is life-threatening and that the financial and emotional trauma, irrespective the circumstances, can never be undone, your public attack and defamatory statements and accusations cannot be justified. We note that you failed to mention that you have already filed a complaint against Genesis with the Council for Medical Schemes and that rather than wait for a ruling, you have decided to attack Genesis in public. Yours sincerely

GENESIS MEDICAL SCHEME

Genesis Medical Scheme's reply25 Jun 2019, 07:48

Official