1 reviews | Active since Dec 2017
Genesis Refuses To Pay For Pathology But Boast Very Low Annual Increases
So Genesis has chosen to not pay (***) for any pathology whatsoever in spite of the specialist providing his explanation for requesting the tests which have confirmed that something is not right and potentially sinister. It confirmed Pre Diabetes and very high Ferritin levels. On one hand they state that, for want of a better description, they dont "second guess the doctor" but on the other hand they now refuse to pay for the pathology the Specialist Doctor deemed necessary to make a full and proper diagnosis. So now I expect Genesis to place itself on record that either they consider me personally dishonest or that the they dont trust the doctor? I can assure you my own integrity is not in question.
It seems no little wonder that Genesis's increases are so low - maybe because they use chicanery to avoid payments.
Be Warned!
Dear Mr Swart
Our initial and subsequent response to your first review remains relevant, and there is no further information that we can add that would change the position already communicated to you.
To clarify, no new or relevant information has been provided that would demonstrate the clinical appropriateness or medical necessity of the additional pathology tests performed during your admission.
The two pathology tests you specifically refer to, which confirmed pre-diabetes and elevated ferritin levels, were unrelated to the clinical reason for your hospital admission. As you are aware, your admission for the relevant condition was funded by the Scheme. However, the two additional tests in question, irrespective of the conditions they may have identified, could have been performed on an outpatient basis and were not related to the treatment or management of the condition for which you were admitted to hospital.
By way of example, consider a member who is admitted to hospital for the treatment of pneumonia but, during the same admission, undergoes a sleep study. Although the sleep study may identify a separate medical condition, it is not related to the diagnosis or treatment of the pneumonia. The sleep study would therefore not be considered part of the clinically necessary treatment associated with that admission, and the associated cost would be for the member’s own account.
The same principle applies to the pathology tests in question. The fact that tests were performed while you were in hospital does not, in itself, mean that they are automatically eligible for funding by the Scheme. Medical schemes assess claims in accordance with the clinical relevance and medical necessity of the services provided in relation to the condition being treated.
As explained in our previous response, the situation you have experienced, where certain claims were funded and others were not, is not unique to Genesis members. It reflects a broader and increasingly significant challenge within the medical schemes and private healthcare environment regarding the appropriate use and funding of healthcare services.
It is important to distinguish between services that are clinically necessary and related to the condition for which a member is admitted, and additional investigations that may identify or assess unrelated conditions. Medical schemes are not required to fund every investigation or test performed during a hospital admission simply because the member is an inpatient at the time. Funding is based on the clinical appropriateness and relevance of the services to the condition being treated.
Where additional investigations are performed to investigate or identify conditions unrelated to the reason for admission, and where those investigations could appropriately have been performed outside of the hospital admission, the associated costs may not be funded by the Scheme and may therefore be for the member’s own account.
We trust that this explanation provides further clarity regarding the reasons why the pathology claims in question were not funded by the Scheme.
Regarding your final remarks, please be assured that we have absolutely no reason to believe that you are being dishonest. We fully understand that you are simply seeking full funding of your claims, and we appreciate and understand your position.
Please also understand that this is not a matter of whether we “trust” your doctor. A member’s treating doctor may treat his or her patient in whatever manner they consider appropriate, and we do not interfere with the treatment decisions made by treating doctors. However, a medical scheme is not necessarily liable for funding all treatment provided, particularly where such treatment is not considered medically appropriate or does not meet the funding criteria in terms of the Scheme’s registered Rules.
In closing, Mr Swart, if you believe that Genesis is not the right scheme for you, we will waive your notice period.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Swart
Our initial and subsequent response to your first review remains relevant, and there is no further information that we can add that would change the position already communicated to you.
To clarify, no new or relevant information has been provided that would demonstrate the clinical appropriateness or medical necessity of the additional pathology tests performed during your admission.
The two pathology tests you specifically refer to, which confirmed pre-diabetes and elevated ferritin levels, were unrelated to the clinical reason for your hospital admission. As you are aware, your admission for the relevant condition was funded by the Scheme. However, the two additional tests in question, irrespective of the conditions they may have identified, could have been performed on an outpatient basis and were not related to the treatment or management of the condition for which you were admitted to hospital.
By way of example, consider a member who is admitted to hospital for the treatment of pneumonia but, during the same admission, undergoes a sleep study. Although the sleep study may identify a separate medical condition, it is not related to the diagnosis or treatment of the pneumonia. The sleep study would therefore not be considered part of the clinically necessary treatment associated with that admission, and the associated cost would be for the member’s own account.
The same principle applies to the pathology tests in question. The fact that tests were performed while you were in hospital does not, in itself, mean that they are automatically eligible for funding by the Scheme. Medical schemes assess claims in accordance with the clinical relevance and medical necessity of the services provided in relation to the condition being treated.
As explained in our previous response, the situation you have experienced, where certain claims were funded and others were not, is not unique to Genesis members. It reflects a broader and increasingly significant challenge within the medical schemes and private healthcare environment regarding the appropriate use and funding of healthcare services.
It is important to distinguish between services that are clinically necessary and related to the condition for which a member is admitted, and additional investigations that may identify or assess unrelated conditions. Medical schemes are not required to fund every investigation or test performed during a hospital admission simply because the member is an inpatient at the time. Funding is based on the clinical appropriateness and relevance of the services to the condition being treated.
Where additional investigations are performed to investigate or identify conditions unrelated to the reason for admission, and where those investigations could appropriately have been performed outside of the hospital admission, the associated costs may not be funded by the Scheme and may therefore be for the member’s own account.
We trust that this explanation provides further clarity regarding the reasons why the pathology claims in question were not funded by the Scheme.
Regarding your final remarks, please be assured that we have absolutely no reason to believe that you are being dishonest. We fully understand that you are simply seeking full funding of your claims, and we appreciate and understand your position.
Please also understand that this is not a matter of whether we “trust” your doctor. A member’s treating doctor may treat his or her patient in whatever manner they consider appropriate, and we do not interfere with the treatment decisions made by treating doctors. However, a medical scheme is not necessarily liable for funding all treatment provided, particularly where such treatment is not considered medically appropriate or does not meet the funding criteria in terms of the Scheme’s registered Rules.
In closing, Mr Swart, if you believe that Genesis is not the right scheme for you, we will waive your notice period.
Yours sincerely
GENESIS MEDICAL SCHEME