JK
Jorgen K
1 reviews | Active since Dec 2013
10 May 2023, 09:54
Genesis Medical Aid - ABSOLUTELY PATHETIC!!!
Absolutely pathetic!! I am a mental healthcare worker who has a patient who needs admission due to severe suicidal ideation.
They do not abide to any law whatsoever and the only thing that is important to them is the bottom line. They always come with lame excuses.
No respect whatsoever for Prescribes Minimum Benefits and they force their patients to go to State Facilities, which are in total chaos.
Why have a medical aid if you do not get ANY benefits for your medical aid?
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Genesis Medical Scheme's replyOfficial
11 May 2023, 11:33Dear Dr Kahler
Your feedback is rather unfortunate as your accusations are completely unfounded, incorrect and in fact, defamatory.
The “law” that your refer to in this instance, is the Medical Schemes Act 131 of 1998 (“the Act”). The Registrar of Medical Schemes, in his capacity as regulator of the industry, declared the rules of Genesis to be consistent with the Act and fair to members.
Genesis does not provide medical services or treatment to members; nor does the Scheme advise about how and where a member’s condition should be treated. The role of the Scheme is to reimburse the qualifying claims of members strictly in terms of the rules of the Scheme and the benefit option selected by the member.
If and when a member chose to be treated in a private hospital / facility for one of the PMB conditions, then their claim will be subject (and may be limited) to the benefits that apply to their selected benefit option. For admissions related to mental illness conditions - the Scheme Rules make provision for hospitalisation in a health establishment registered in terms of Section 5 of the Mental Health Act of 2002. This benefit is limited to the PMB conditions listed in Annexure A to the regulations to the Act under the heading “Mental Illness” and is further limited to the treatment prescribed in the regulation as applicable to the specific DTP code diagnosed and the treatment must follow the predominant Public Hospital practice. In a non-DSP facility, this benefit is limited to R42 000 per beneficiary per annum.
Members are not forced (as you assert) to seek treatment in a public hospital just because there is a DSP in their area. If, however, there is a DSP in their area and they choose to be treated for a PMB condition in a private hospital, then they will be liable for the difference (if any) between the registered benefits of their selected benefit option and the actual costs incurred in the treatment they receive in a private hospital.
All medical schemes in SA pay claims in accordance with their registered benefits and this has nothing to do with a “bottom line”, as you assert. Also bear in mind the opposite question that is often raised, namely, will a provider treat a patient without any benefits to their bottom line?
Furthermore, what is also deplorable in some instances, is practitioners' lack of knowledge on the funding provisions of PMBs in the Act. We encourage you to fami****ise yourself with sections 29(1)(o), 29(1)(p) & 29(1)(q) of the Act, as well as regulation 8, which is subject to the provisions of section 29 as mentioned, before you continue with any further defamatory allegations. All our rights in law are reserved.
Yours sincerely
GENESIS MEDICAL SCHEME
Genesis Medical Scheme's reply11 May 2023, 11:33
Official
Dear Dr Kahler
Your feedback is rather unfortunate as your accusations are completely unfounded, incorrect and in fact, defamatory.
The “law” that your refer to in this instance, is the Medical Schemes Act 131 of 1998 (“the Act”). The Registrar of Medical Schemes, in his capacity as regulator of the industry, declared the rules of Genesis to be consistent with the Act and fair to members.
Genesis does not provide medical services or treatment to members; nor does the Scheme advise about how and where a member’s condition should be treated. The role of the Scheme is to reimburse the qualifying claims of members strictly in terms of the rules of the Scheme and the benefit option selected by the member.
If and when a member chose to be treated in a private hospital / facility for one of the PMB conditions, then their claim will be subject (and may be limited) to the benefits that apply to their selected benefit option. For admissions related to mental illness conditions - the Scheme Rules make provision for hospitalisation in a health establishment registered in terms of Section 5 of the Mental Health Act of 2002. This benefit is limited to the PMB conditions listed in Annexure A to the regulations to the Act under the heading “Mental Illness” and is further limited to the treatment prescribed in the regulation as applicable to the specific DTP code diagnosed and the treatment must follow the predominant Public Hospital practice. In a non-DSP facility, this benefit is limited to R42 000 per beneficiary per annum.
Members are not forced (as you assert) to seek treatment in a public hospital just because there is a DSP in their area. If, however, there is a DSP in their area and they choose to be treated for a PMB condition in a private hospital, then they will be liable for the difference (if any) between the registered benefits of their selected benefit option and the actual costs incurred in the treatment they receive in a private hospital.
All medical schemes in SA pay claims in accordance with their registered benefits and this has nothing to do with a “bottom line”, as you assert. Also bear in mind the opposite question that is often raised, namely, will a provider treat a patient without any benefits to their bottom line?
Furthermore, what is also deplorable in some instances, is practitioners' lack of knowledge on the funding provisions of PMBs in the Act. We encourage you to fami****ise yourself with sections 29(1)(o), 29(1)(p) & 29(1)(q) of the Act, as well as regulation 8, which is subject to the provisions of section 29 as mentioned, before you continue with any further defamatory allegations. All our rights in law are reserved.
Yours sincerely
GENESIS MEDICAL SCHEME