Medgap – “Seamless” Claims process doesn't seem to be seamless to me

I got myself Gapcover from Medgap (underwritten by GuardRisk) some years ago and have never claimed from Gapcover before. (Medgap itself isn't registered on Hellopeter) What I thought is going to be a “Seamless” claim process, is not. It turns out that not even a direct payment to the hospital for the amount of R 30,000.00, qualifies to be refunded in a short amount of time. The original literature stated that if you are a member of Bonitas or Medgap, a Medgap member qualifies for the seamless process, whereby a Medgap member isn’t involved in the claim process. You are supposed to give authorization for your information to be shared between Bonitas and Medgap, before you can qualify for the seamless process. That was the main reason why I have chosen Medgap, in the first place.

I am confused about the Medgap claim process:

- I have sent proof of payment of the above-mentioned R 30,000.00 to the claims email address reflected on the new policy document I received during 2023, after upgrading my medical aid plan. I was under the impression that I am still opted in, for the seamless claim process and have sent the proof of payment as a courtesy notification. - My proof of payment was then forwarded to another email address and fortunately, I was copied in on that email correspondence. - Eventually, four days later, a claims Assessor from “Admed” whoever that is, send me an email about the seamless process again, stating that the claim will eventually start, once the claim is finalized by the medical aid. So, I am assuming that this is confirmation that I am still registered for the seamless process. - Two days after sending through my proof of payment, I remembered that I have also chosen our Bonitas medical aid Broker, as a broker for Medgap. So, I send my broker an email, requesting help with the claim, as at that stage no one from Medgap has rep**** to my claim email. The correspondence that the broker received from Medgap, indicated a manual claim process again. Medgap gave our broker a manual claim form “dated as claims for the 2022 year” and stated that whenever Bonitas send the statement for the month of May, which is somewhere in June, then only can I complete this manual claim form.

- The claim is for a shortfall on an internal prosthesis for my wife.

I never thought I will refer to SARS as a good example, but even SARS refunds you between 48 – 72 hours.

In my mind, a seamless process would definitely all be done online and you as the member or insured don't have to complete any forms and your refund must be paid to you within 5 - 7 working days.

I accept that you must as the claimant must at least upload the proof of payment. Now I have to wait for the Bonitas statement before the claim can be lodged.

The other problem is that the Bonitas statement doesn't reflect any hospital expenses paid by yourself, that aren't covered by care programs. My wife was treated under a Bonitas care program and the people from Ampath came to inform my wife about their invoice for blood tests from the previous day, less than 24 hours after she had the actual operation. Those invoices from Ampath won't be reflected on any Bonitas statement, so it seems to me that you won't be able to claim any medical expenses if it doesn't appear on your medical aid statement???