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BRIAN B
1 reviews | Active since Jul 2013
06 Apr 2023, 13:50
Wasted funds on Medical scheme
Been with them for about 10 years and hardly needed them. They do not pay for doctor, specialist x-rays, blood tests. optics, etc.. Really an hospital plan and ready to help if you find yourself admitted into hospital. It is advocated that you can use any service provider accepting to pay the difference in cost claimed above the schemes rates. What they are not telling you is that your preferred specialist will not be able to service you in their preferred government hospital. Your specialist probably will not operate in the preferred hospitals and your specialist findings will have no impact at these facilities and you will be required to do the musical chairs thing to open a file and thereafter start with a government doctor appointment followed by government specialist. This makes it very clear to me - You are wasting your money and should just go full out government patient. That is what it really means unless you have unlimited funds available to waste on a scheme like Genesis.
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Genesis Medical Scheme's replyOfficial
06 Apr 2023, 15:12Dear Mr Baker
No funds on a medical scheme are ever wasted. Medical scheme cover works like any short- or long term insurance policy. You may pay for years without ever using it, or you may claim millions of Rands shortly after joining as a policyholder / member.
Hospital plans in South Africa provide cover for mostly in-hospital treatment. Out-of-hospital costs associated with doctors’ consultations, optometry, acute medication, etc. are always covered by the member. It is not “Genesis” that doesn’t pay for these services - that is how hospital plans in South Africa are structured. Medical scheme benefit options that do provide cover for out-of-hospital treatment usually reimburse members’ claims from the members’ available savings benefits. These are however medical aid plans that are structured differently. Hospital plans don’t have medical savings facilities.
Regarding your feedback / interpretation on members’ use of private doctors / specialists / hospitals vs having the option to use our designated service provider (state) - it seems as if your interpretation of these benefits / guidelines are flawed.
Members of Genesis are not forced 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 between what the doctor charges and the Genesis Scheme Tariff (unless they have gap cover). All medical schemes in South Africa work on the exact same principle.
Below is a link that explains the use of private healthcare service providers vs using DSPs.
Regarding the enquiry that you had with us this morning - please let us know if you have any further questions. We will gladly provide further guidance. It is important to note that Genesis has not rejected your initial application for the benefit concerned. The outstanding information is a specific requirement in terms of the algorithms listed in the Medical Schemes Act. Again - no medical scheme in SA will approve chronic funding benefits if certain requirements are not met.
We acknowledge your frustration in this regard, but having said that, medical schemes cannot register these kind of benefits unless certain clinical criteria are met. These criteria are also not at the discretion of a medical scheme - they are very specific in terms of the algorithms listed in the Medical Schemes Act.
We will give you call again and follow up on your progress in this regard.
Yours sincerely
GENESIS MEDICAL SCHEME
Genesis Medical Scheme's reply06 Apr 2023, 15:12
Official
Dear Mr Baker
No funds on a medical scheme are ever wasted. Medical scheme cover works like any short- or long term insurance policy. You may pay for years without ever using it, or you may claim millions of Rands shortly after joining as a policyholder / member.
Hospital plans in South Africa provide cover for mostly in-hospital treatment. Out-of-hospital costs associated with doctors’ consultations, optometry, acute medication, etc. are always covered by the member. It is not “Genesis” that doesn’t pay for these services - that is how hospital plans in South Africa are structured. Medical scheme benefit options that do provide cover for out-of-hospital treatment usually reimburse members’ claims from the members’ available savings benefits. These are however medical aid plans that are structured differently. Hospital plans don’t have medical savings facilities.
Regarding your feedback / interpretation on members’ use of private doctors / specialists / hospitals vs having the option to use our designated service provider (state) - it seems as if your interpretation of these benefits / guidelines are flawed.
Members of Genesis are not forced 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 between what the doctor charges and the Genesis Scheme Tariff (unless they have gap cover). All medical schemes in South Africa work on the exact same principle.
Below is a link that explains the use of private healthcare service providers vs using DSPs.
Regarding the enquiry that you had with us this morning - please let us know if you have any further questions. We will gladly provide further guidance. It is important to note that Genesis has not rejected your initial application for the benefit concerned. The outstanding information is a specific requirement in terms of the algorithms listed in the Medical Schemes Act. Again - no medical scheme in SA will approve chronic funding benefits if certain requirements are not met.
We acknowledge your frustration in this regard, but having said that, medical schemes cannot register these kind of benefits unless certain clinical criteria are met. These criteria are also not at the discretion of a medical scheme - they are very specific in terms of the algorithms listed in the Medical Schemes Act.
We will give you call again and follow up on your progress in this regard.
Yours sincerely
GENESIS MEDICAL SCHEME
BB
BRIAN B's updateReviewer Update
07 Apr 2023, 10:54Impressive political-like reply.
I did not mention that I was told to spend another R 1800 to satisfy your precious algorithm to have a benefit worth R 450. Was also told during a phone call after informing them that we, as 10 year long pensioners did not have the funds for meeting the criteria, that if the results shows that the requested medication is in fact needed the required test at R1 350 would be paid by genesis and the chronic benefit would be approved. Unfortunately this can not be trusted as there would surely be yet another algorithm not allowing for this to be paid for.
Genesis must be very proud of the management of funds available to the members. It is unfortunately also an indication of how much is actually spent on the members. The rest is probably for expanding business by adding banking, insurance and probably more.
My initial review was merely to warn persons with limited means who cannot afford their expensive cover PLUS the gap cover to rather save their money and use their preferred Government hospitals without having to pay Genesis.
Now say what you like - The reviews on Genesis implicates the true standing. Poor! Poor! Poor!
I did not mention that I was told to spend another R 1800 to satisfy your precious algorithm to have a benefit worth R 450. Was also told during a phone call after informing them that we, as 10 year long pensioners did not have the funds for meeting the criteria, that if the results shows that the requested medication is in fact needed the required test at R1 350 would be paid by genesis and the chronic benefit would be approved. Unfortunately this can not be trusted as there would surely be yet another algorithm not allowing for this to be paid for.
Genesis must be very proud of the management of funds available to the members. It is unfortunately also an indication of how much is actually spent on the members. The rest is probably for expanding business by adding banking, insurance and probably more.
My initial review was merely to warn persons with limited means who cannot afford their expensive cover PLUS the gap cover to rather save their money and use their preferred Government hospitals without having to pay Genesis.
Now say what you like - The reviews on Genesis implicates the true standing. Poor! Poor! Poor!
BB
BRIAN B's update07 Apr 2023, 10:54
Reviewer Update
Impressive political-like reply.
I did not mention that I was told to spend another R 1800 to satisfy your precious algorithm to have a benefit worth R 450. Was also told during a phone call after informing them that we, as 10 year long pensioners did not have the funds for meeting the criteria, that if the results shows that the requested medication is in fact needed the required test at R1 350 would be paid by genesis and the chronic benefit would be approved. Unfortunately this can not be trusted as there would surely be yet another algorithm not allowing for this to be paid for.
Genesis must be very proud of the management of funds available to the members. It is unfortunately also an indication of how much is actually spent on the members. The rest is probably for expanding business by adding banking, insurance and probably more.
My initial review was merely to warn persons with limited means who cannot afford their expensive cover PLUS the gap cover to rather save their money and use their preferred Government hospitals without having to pay Genesis.
Now say what you like - The reviews on Genesis implicates the true standing. Poor! Poor! Poor!
I did not mention that I was told to spend another R 1800 to satisfy your precious algorithm to have a benefit worth R 450. Was also told during a phone call after informing them that we, as 10 year long pensioners did not have the funds for meeting the criteria, that if the results shows that the requested medication is in fact needed the required test at R1 350 would be paid by genesis and the chronic benefit would be approved. Unfortunately this can not be trusted as there would surely be yet another algorithm not allowing for this to be paid for.
Genesis must be very proud of the management of funds available to the members. It is unfortunately also an indication of how much is actually spent on the members. The rest is probably for expanding business by adding banking, insurance and probably more.
My initial review was merely to warn persons with limited means who cannot afford their expensive cover PLUS the gap cover to rather save their money and use their preferred Government hospitals without having to pay Genesis.
Now say what you like - The reviews on Genesis implicates the true standing. Poor! Poor! Poor!