1 reviews | Active since Apr 2013
Hospital account NOT being paid at all by Genesis Medical Aid!!!!
PLEASE BEWARE OF FALLING PREY TO THIS MEDICAL AID!!!! My daughter was admitted into Netcare hospital in July 2018 for 3 days for a heart condition. Genesis only agreed to pay for 1 day??? According to Genesis, she should have spent only 1 day. HOW can my 17 year old daughter (with NO medical qualifications) question the Netcare hospital Dr's prescribed treatment??? In spite of us even obtaining a motivational letter from the Dr explaining in detail, treatment administered,,,, we are still waiting for a response until today. ALL hospital, Drs, pathologists etc. claims have been rejected for the 2 days. We are currently being inundated with accounts from Drs threatening to hand over accounts to Debt collectors as 3 moths have already passed by. JOKE of the day; Genesis website reads: "Our hospital plans will cover you in hospital for planned and emergency hospital admissions. While your focus should be on getting better, we will provide you with the welcome peace of mind that your hospital and related accounts will be taken care of." IS THIS HOW YOUR WELCOME PEACE OF MIND AND ACOUNTS ARE TAKEN CARE OF?????????? Most misleading according to Consumer Protection Act. After being a member for 13 years..... this is the level of service received. Will DEFINITELY be taking this matter forward to the Ombudsman.
Dear Mr Shaik
We will look into your query and respond soonest.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Shaik
We will look into your query and respond soonest.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Shaik
First of all, we would like to apologise for the inconvenience and uncer*****y regarding the payment of claims that followed your daughter’s recent hospital admission.
From the Scheme’s perspective, we would like to clarify some aspects around the payment of claims for this admission. As a medical scheme, our responsibility is the funding of qualifying member claims. When a patient is admitted into hospital and treatment is received, the Scheme will fund the treatment relating to the admission, on the condition that certain criteria are met as per the Scheme Rules. Medical schemes, as a rule, will not fund hospital admissions for the sole purpose of doing diagnostic tests, of for treatment that is not deemed medically appropriate (https://www.genesismedical.co.za/good2know/understand-funding-for-hospital-admissions-part-3-of-3/).
In your daughter’s instance, there was no hospital-based treatment indicated for her 2nd and 3rd days in hospital and for this reason, we initially only funded the 1st day of her admission. Medical schemes cannot arbitrarily admit and pay claims without having all the information required to validate a claim(s). As a result and at the time, we requested additional clinical information from the hospital for your daughter’s extended length of stay. Three weeks after our initial request for additional information, the hospital informed us that no further treatment was done on those two days and that no additional information was available. At that stage, the funding decision of the Scheme remained unchanged.
On the 1st October 2018, your wife sent us a letter from your daughter’s treating doctor. This additional information was then reviewed by the Scheme and as a result, the last two days of your daughter’s admission will now be funded.
We trust that you will find this explanation in order. Further to this, we would like to reassure you that the non-payment of claims (if any) from the Scheme’s perspective is always a well thought-through process. It is our responsibility to apply good governance in terms of our Scheme Rules and to audit all claims in line with our definition of “medically appropriate treatment. We have to ensure that the Rules are app**** fairly and consistently to both the benefit and the protection of our membership as a whole. It is as a result of our good governance that we are able to contain costs and in turn, pass this benefit on to all our members in the form of low annual contribution increases.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Shaik
First of all, we would like to apologise for the inconvenience and uncer*****y regarding the payment of claims that followed your daughter’s recent hospital admission.
From the Scheme’s perspective, we would like to clarify some aspects around the payment of claims for this admission. As a medical scheme, our responsibility is the funding of qualifying member claims. When a patient is admitted into hospital and treatment is received, the Scheme will fund the treatment relating to the admission, on the condition that certain criteria are met as per the Scheme Rules. Medical schemes, as a rule, will not fund hospital admissions for the sole purpose of doing diagnostic tests, of for treatment that is not deemed medically appropriate (https://www.genesismedical.co.za/good2know/understand-funding-for-hospital-admissions-part-3-of-3/).
In your daughter’s instance, there was no hospital-based treatment indicated for her 2nd and 3rd days in hospital and for this reason, we initially only funded the 1st day of her admission. Medical schemes cannot arbitrarily admit and pay claims without having all the information required to validate a claim(s). As a result and at the time, we requested additional clinical information from the hospital for your daughter’s extended length of stay. Three weeks after our initial request for additional information, the hospital informed us that no further treatment was done on those two days and that no additional information was available. At that stage, the funding decision of the Scheme remained unchanged.
On the 1st October 2018, your wife sent us a letter from your daughter’s treating doctor. This additional information was then reviewed by the Scheme and as a result, the last two days of your daughter’s admission will now be funded.
We trust that you will find this explanation in order. Further to this, we would like to reassure you that the non-payment of claims (if any) from the Scheme’s perspective is always a well thought-through process. It is our responsibility to apply good governance in terms of our Scheme Rules and to audit all claims in line with our definition of “medically appropriate treatment. We have to ensure that the Rules are app**** fairly and consistently to both the benefit and the protection of our membership as a whole. It is as a result of our good governance that we are able to contain costs and in turn, pass this benefit on to all our members in the form of low annual contribution increases.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Shaik
Whilst we understand your frustration, we would like to remind you that the hospital account for your daughter’s admission failed to provide a treatment plan for the last two days of her admission. In the absence of a treatment plan, we were unable to process claims. This was not as a result of a fault on our side, or your side. Unfortunately these things do happen from time to time and it takes time to resolve, as we depend on information from the hospital and / or doctors.
As a rule and unless expressly stated to the contrary, all tests done must be directly related to the primary reason for admission to hospital and the funding decision of such tests will ultimately be at the discretion of the Scheme. The one pathology test that was not paid, unfortunately had no relevance to your daughter’s condition at the time. It can be compared to a person that sought admission to hospital with chest pains and then had an X-ray taken of his foot that was troubling him - there was no relevance; hence, a medical scheme will not fund the X-ray.
Medical schemes in South Africa may not and does not provide any medical service or treatment to members. They also do not interfere with any clinical decisions, tests or protocols made by or recommended by your doctor(s).
The fact that a member is in hospital, does not mean that all expenses, tests, treatment and medication received will be covered in full. It has nothing to do with pre-authorisation or, as we refer to it, a hospital admission reference number that is / was issued, as we do not authorise treatment. To put it differently, HOW a member is treated, is entirely up to the expertise and judgement of the member’s doctors / specialists, but whether we will fund such treatment or service(s), depends on the benefits and limits as set out in the Scheme Rules.
Further to this, nothing in our brochure is misleading or is in contravention of any Act. Understandably, it is impossible to list the full set of Scheme Rules in our brochure and it is for this reason that all our brochures state the following: “Whilst every effort has been made to ensure that the benefits set out herein comprise a detailed summary of the relevant Rules of Genesis, any dispute will be resolved by reference to the registered Rules of Genesis approved by the Registrar of Medical Schemes.”
The link to the article that you refer to, was also sent to all our members. It does not specifically have relevance to your case. We compiled a series of three articles, covering the funding of hospital admissions. In South Africa we often have a scenario of what is referred to as “over servicing”, providers charging more that medical aid rates, members not understanding exclusions, treatment that is not deemed medically appropriate, etc. The articles were intended for member education in general.
We have made an effort to communicate with you on this matter and we will continue to be of service to you if there are any further questions from your side.
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mr Shaik
Whilst we understand your frustration, we would like to remind you that the hospital account for your daughter’s admission failed to provide a treatment plan for the last two days of her admission. In the absence of a treatment plan, we were unable to process claims. This was not as a result of a fault on our side, or your side. Unfortunately these things do happen from time to time and it takes time to resolve, as we depend on information from the hospital and / or doctors.
As a rule and unless expressly stated to the contrary, all tests done must be directly related to the primary reason for admission to hospital and the funding decision of such tests will ultimately be at the discretion of the Scheme. The one pathology test that was not paid, unfortunately had no relevance to your daughter’s condition at the time. It can be compared to a person that sought admission to hospital with chest pains and then had an X-ray taken of his foot that was troubling him - there was no relevance; hence, a medical scheme will not fund the X-ray.
Medical schemes in South Africa may not and does not provide any medical service or treatment to members. They also do not interfere with any clinical decisions, tests or protocols made by or recommended by your doctor(s).
The fact that a member is in hospital, does not mean that all expenses, tests, treatment and medication received will be covered in full. It has nothing to do with pre-authorisation or, as we refer to it, a hospital admission reference number that is / was issued, as we do not authorise treatment. To put it differently, HOW a member is treated, is entirely up to the expertise and judgement of the member’s doctors / specialists, but whether we will fund such treatment or service(s), depends on the benefits and limits as set out in the Scheme Rules.
Further to this, nothing in our brochure is misleading or is in contravention of any Act. Understandably, it is impossible to list the full set of Scheme Rules in our brochure and it is for this reason that all our brochures state the following: “Whilst every effort has been made to ensure that the benefits set out herein comprise a detailed summary of the relevant Rules of Genesis, any dispute will be resolved by reference to the registered Rules of Genesis approved by the Registrar of Medical Schemes.”
The link to the article that you refer to, was also sent to all our members. It does not specifically have relevance to your case. We compiled a series of three articles, covering the funding of hospital admissions. In South Africa we often have a scenario of what is referred to as “over servicing”, providers charging more that medical aid rates, members not understanding exclusions, treatment that is not deemed medically appropriate, etc. The articles were intended for member education in general.
We have made an effort to communicate with you on this matter and we will continue to be of service to you if there are any further questions from your side.
Yours sincerely
GENESIS MEDICAL SCHEME