iWyze Trap I mean **** I mean GAP cover. Policy ***

On a beautiful morning in late January, I was commuting to work on my bicycle when a bus travelling very fast hit me for six. it was behind me; so I didn't see it nor even hear it (not that I was wearing headphones). I spent 6 days in ICU, and another week or so in Surgical Ward. I suffered broken rib, collapsed lung, smashed forearm, cracked pelvis, internal bleeding, torn ligaments and muscles, damaged bladder, huge bruising, haematoma and contusions everywhere.

I subsequently had knee reconstructive surgery and spent a further 3 days in hospital.

Whilst in hospital, I had numerous pathology tests, radiology scans, physiotherapy, occupational therapy, psychological therapy etc, in addition to the surgery and huge amounts of medication.

On 31 March I submitted claims, using the very unwieldy and outdated claim form iWyse has. I also explained over the phone to a consultant what had happened to me - Bongiwe Mtshali - who was very friendly and helpful, and confirmed I didn't need to submit separate claim forms for every different service provider (there were lots), but could send on one form, and then just send the service provider invoices for all the rest., which is what I did.

On 8 April, Bongiwe emailed me, saying my claims weren't covered because the services rendered were out-patient services i.e. rendered whilst I was not admitted to hospital. She also tried calling me but I was in meetings. I emailed back, disagreeing, as it was obvious I was in-hospital when receiving the treatments, as I had provided the dates I was in hospital when submitting my claim.

Only then did she ask for 'detailed medical aid statements'. It took a while to get these from the medical aid. I sent the statements to her on 15 April. I heard nothing back, and sent a reminder on 5 May. She called me, and followed this up with an email the next day, saying the claims were still rejected, now on the grounds that the medical aid had rejected, and therefore so would the gap cover not pay i.e. if the medical aid doesn't cover the condition, there is no 'gap', thus the gap policy can't pay. However, what she missed (avoided seeing?) is that the medaid did partially pay, but because of sub-limits for services like physiotherapy, did not pay all the costs. This is precisely the 'gap', that gap cover fills. Or so I thought.

Anyhoo. I then took out their policy wording and had a good read. Then I emailed Bongiwe my thoughts on 6 May. Which effectively was that I disagreed, and quoting the policy, noted its intention is to 'provide cover for the shortfall between what a medical practitioner charges and what your medical scheme pays, for any in-hospital surgical procedure or for certain out-of-hospital surgical procedures. iWYZE Gap Cover also insures against co-payments or deductibles which may be levied against you by your medical scheme, for certain procedures'.

Seemed very clear to me. But not so Bongiwe, who took until 19 May to revert and tell me under Exclusion 6.1.1. that the policy excludes 'Any claim that is excluded or rejected by the Eligible Member’s Medical Scheme'. Which once again misses the obvious. My medaid didn't reject these claims. It paid them until the sublimit for such services was reached, and then started rejecting any further amounts.

Put another way, the medaid paid for example, my physiotherapy in hospital, up to an amount of say R15000 (being a theoretical sub-limit). I received R20000 of physiotherapy services in hospital. So. A R5000 shortfall. This R5000 Iwyze is rejecting due to it being excluded by the medaid. Ridiculous? I sure think so.

I then asked Bongiwe the same day who I can escalate this to - she responded the same day to say she has she has sent the emails to her supervisor (the no name brand type) who will contact me. As of today, I have yet to hear back from No Name Brand.

As a last shot, I did point Bongiwe to the language in the policy which states under clause 3.5 and 3.6. that:

3.5 Benefits relating to this clause will only be compensated in respect of a service, provided during a Hospital Episode, where the charges relating to the service supp**** has exceeded a relevant Benefit sub-limit of the member's Medical Scheme Benefit option. 3.6 The Benefit payable is equal to the charged amount less the amount compensated by the Eligible Member's Medical Scheme subject to a maximum of R17 500 (seventeen thousand five hundred rand) per event or medical condition.

Which clearly encompasses the circumstances of my claims.

I alerted Iwyze that I would be Hello-Petering them, and reporting my claim to the ombud. Clearly this had no effect, as I have heard nothing back from them since 19 May.

Poor show Old Mutual Insure.