LV
Louis V
1 reviews | Active since Jan 2024
25 Jan 2024, 10:37
No payment after Accident..
December I was involved in a MVA on my way home from work, after getting approval from genesis to be admitted to hospital and undergoing the necessary treatment genesis did a 180 and phoned all the service providers and told them they wont pay for anything because it was an IOD according to them.. NOWHERE on ANY of there rules does it state there will be no payment incase of a suspected IOD.. been with genesis for almost six years and the first time I really needed them they dont want to help.. They are quick to take your money but they DO NOT cover you when you need it.. TERRIBLE SERVICE..
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Replies (3)
Genesis Medical Scheme's replyOfficial
25 Jan 2024, 14:49Dear Louis We don’t quite understand your complaint, as your accident and subsequent treatment were related to an injury on duty (IOD) and for which a claim was submitted under the provisions of the Workmans Compensation Act (WCA). You are furthermore in possession of the case number. Your accident was also not a “suspected” IOD - it was an actual IOD. This fact was established after the relevant Injury Report Form was received by the Scheme. The WCA Fund covers the cost of medical treatment when an employee was injured on duty. Medical schemes are therefore not liable for these costs where an employer contributions to the WCA Fund. If your accident was not related to an injury on duty, the medical scheme would have paid all medically appropriate and qualifying claims. All medical schemes in South Africa work like this. We trust that our feedback will clarify the matter. Yours sincerely GENESIS MEDICAL SCHEME
Genesis Medical Scheme's reply25 Jan 2024, 14:49
Official
Dear Louis We don’t quite understand your complaint, as your accident and subsequent treatment were related to an injury on duty (IOD) and for which a claim was submitted under the provisions of the Workmans Compensation Act (WCA). You are furthermore in possession of the case number. Your accident was also not a “suspected” IOD - it was an actual IOD. This fact was established after the relevant Injury Report Form was received by the Scheme. The WCA Fund covers the cost of medical treatment when an employee was injured on duty. Medical schemes are therefore not liable for these costs where an employer contributions to the WCA Fund. If your accident was not related to an injury on duty, the medical scheme would have paid all medically appropriate and qualifying claims. All medical schemes in South Africa work like this. We trust that our feedback will clarify the matter. Yours sincerely GENESIS MEDICAL SCHEME
LV
Louis V's updateReviewer Update
25 Jan 2024, 14:5916.5 Possible Recovery from Third Parties
16.5.1 Claims for the treatment of injuries or expenses recoverable from
third parties must be supported by a report setting out the
circumstances in which the injury or accident was sustained and
providing full details of all parties involved.
16.5.2 In the case where the injury gives rise to a claim in contract, delict
or statute (for instance a motor vehicle accident or third party
claim) the Scheme shall advance the benefits to which the
beneficiary is entitled in terms of these Rules on condition that
the beneficiary appoints an attorney to act on his/her behalf in
order to recover damages for the injury.
16.5.3 The beneficiary shall irrevocably instruct the attorney
representing him to pay over to the Scheme the advance made in
terms of clause 16.5.2 and ensure that the attorney signs a
written undertaking to this effect in favour of the Scheme. Should
the beneficiary have to change attorneys for any reason, the
beneficiary shall notify the Scheme in writing and ensure that the
new attorney signs the same undertaking to the Scheme.
16.5.4 Should the beneficiary fail to instruct an attorney, the Scheme shall
be entitled, but not obliged, at its own cost to appoint one or
more attorneys for purposes of pursuing any claim that arises as
a result of the injury or accident to the beneficiary. The
beneficiary shall be obliged to co-operate fully with the Scheme
and such attorneys instructed in the matter. In such
circumstances the beneficiary will not be liable for any legal costs
in the event of the unsuccessful pursuit of a claim.
Please see your scheme rules..
What happens if the RMA does not accept liability?
Who will be responsible for the medical bills?
16.5.1 Claims for the treatment of injuries or expenses recoverable from
third parties must be supported by a report setting out the
circumstances in which the injury or accident was sustained and
providing full details of all parties involved.
16.5.2 In the case where the injury gives rise to a claim in contract, delict
or statute (for instance a motor vehicle accident or third party
claim) the Scheme shall advance the benefits to which the
beneficiary is entitled in terms of these Rules on condition that
the beneficiary appoints an attorney to act on his/her behalf in
order to recover damages for the injury.
16.5.3 The beneficiary shall irrevocably instruct the attorney
representing him to pay over to the Scheme the advance made in
terms of clause 16.5.2 and ensure that the attorney signs a
written undertaking to this effect in favour of the Scheme. Should
the beneficiary have to change attorneys for any reason, the
beneficiary shall notify the Scheme in writing and ensure that the
new attorney signs the same undertaking to the Scheme.
16.5.4 Should the beneficiary fail to instruct an attorney, the Scheme shall
be entitled, but not obliged, at its own cost to appoint one or
more attorneys for purposes of pursuing any claim that arises as
a result of the injury or accident to the beneficiary. The
beneficiary shall be obliged to co-operate fully with the Scheme
and such attorneys instructed in the matter. In such
circumstances the beneficiary will not be liable for any legal costs
in the event of the unsuccessful pursuit of a claim.
Please see your scheme rules..
What happens if the RMA does not accept liability?
Who will be responsible for the medical bills?
LV
Louis V's update25 Jan 2024, 14:59
Reviewer Update
16.5 Possible Recovery from Third Parties
16.5.1 Claims for the treatment of injuries or expenses recoverable from
third parties must be supported by a report setting out the
circumstances in which the injury or accident was sustained and
providing full details of all parties involved.
16.5.2 In the case where the injury gives rise to a claim in contract, delict
or statute (for instance a motor vehicle accident or third party
claim) the Scheme shall advance the benefits to which the
beneficiary is entitled in terms of these Rules on condition that
the beneficiary appoints an attorney to act on his/her behalf in
order to recover damages for the injury.
16.5.3 The beneficiary shall irrevocably instruct the attorney
representing him to pay over to the Scheme the advance made in
terms of clause 16.5.2 and ensure that the attorney signs a
written undertaking to this effect in favour of the Scheme. Should
the beneficiary have to change attorneys for any reason, the
beneficiary shall notify the Scheme in writing and ensure that the
new attorney signs the same undertaking to the Scheme.
16.5.4 Should the beneficiary fail to instruct an attorney, the Scheme shall
be entitled, but not obliged, at its own cost to appoint one or
more attorneys for purposes of pursuing any claim that arises as
a result of the injury or accident to the beneficiary. The
beneficiary shall be obliged to co-operate fully with the Scheme
and such attorneys instructed in the matter. In such
circumstances the beneficiary will not be liable for any legal costs
in the event of the unsuccessful pursuit of a claim.
Please see your scheme rules..
What happens if the RMA does not accept liability?
Who will be responsible for the medical bills?
16.5.1 Claims for the treatment of injuries or expenses recoverable from
third parties must be supported by a report setting out the
circumstances in which the injury or accident was sustained and
providing full details of all parties involved.
16.5.2 In the case where the injury gives rise to a claim in contract, delict
or statute (for instance a motor vehicle accident or third party
claim) the Scheme shall advance the benefits to which the
beneficiary is entitled in terms of these Rules on condition that
the beneficiary appoints an attorney to act on his/her behalf in
order to recover damages for the injury.
16.5.3 The beneficiary shall irrevocably instruct the attorney
representing him to pay over to the Scheme the advance made in
terms of clause 16.5.2 and ensure that the attorney signs a
written undertaking to this effect in favour of the Scheme. Should
the beneficiary have to change attorneys for any reason, the
beneficiary shall notify the Scheme in writing and ensure that the
new attorney signs the same undertaking to the Scheme.
16.5.4 Should the beneficiary fail to instruct an attorney, the Scheme shall
be entitled, but not obliged, at its own cost to appoint one or
more attorneys for purposes of pursuing any claim that arises as
a result of the injury or accident to the beneficiary. The
beneficiary shall be obliged to co-operate fully with the Scheme
and such attorneys instructed in the matter. In such
circumstances the beneficiary will not be liable for any legal costs
in the event of the unsuccessful pursuit of a claim.
Please see your scheme rules..
What happens if the RMA does not accept liability?
Who will be responsible for the medical bills?
Genesis Medical Scheme's replyOfficial
26 Jan 2024, 11:54 Dear Louis Our Rule 16 would be of relevance if, for example, you submitted a claim against the Road Accident Fund (RAF). In such cases you (or your medical scheme) would have appointed an attorney and signed an undertaking to reimburse the Scheme once you are paid out the SINGLE claim against the RAF. Your claim , however, is not with the RAF, but under the WCA, which your employer contributes to. You have been given a case number, which means that the Compensation Fund will pay all your medical expenses for up to two years from the date of the accident. Unlike a RAF claim, which is a single claim, your claim under the Compensation Fund is managed differently, for example, all service providers (the hospital as well as every service provider that was involved in your treatment) will claim directly from the Fund and the Fund will pay them directly. Genesis is not involved in this process. To reiterate - if your accident was not related to an IOD claim, the Scheme would have covered your medical expenses and then a further claim could be submitted to the RAF. We have explained the process to the main member of your medical aid and it was our understanding that everything was understood, however, we are happy to give you a call to put your mind at rest. Yours sincerely GENESIS MEDICAL SCHEME
Genesis Medical Scheme's reply26 Jan 2024, 11:54
Official
Dear Louis Our Rule 16 would be of relevance if, for example, you submitted a claim against the Road Accident Fund (RAF). In such cases you (or your medical scheme) would have appointed an attorney and signed an undertaking to reimburse the Scheme once you are paid out the SINGLE claim against the RAF. Your claim , however, is not with the RAF, but under the WCA, which your employer contributes to. You have been given a case number, which means that the Compensation Fund will pay all your medical expenses for up to two years from the date of the accident. Unlike a RAF claim, which is a single claim, your claim under the Compensation Fund is managed differently, for example, all service providers (the hospital as well as every service provider that was involved in your treatment) will claim directly from the Fund and the Fund will pay them directly. Genesis is not involved in this process. To reiterate - if your accident was not related to an IOD claim, the Scheme would have covered your medical expenses and then a further claim could be submitted to the RAF. We have explained the process to the main member of your medical aid and it was our understanding that everything was understood, however, we are happy to give you a call to put your mind at rest. Yours sincerely GENESIS MEDICAL SCHEME