Outcome of the co-payment issue

I am lodging a formal complaint regarding the handling of my Gap Cover claim - Despite following the required process and obtaining pre-authorisation from my medical aid scheme.

Kaelo Old Mutual Gap Cover Policy *** Gap Claim - Reference Number ***

This claim relates to a Nephrectomy surgical procedure performed on 18 August 2026 at Urology Hospital following a ICD 10 code diagnosis. I am deeply dissatisfied with both the outcome of the claim assessment and the manner in which the matter has been handled by Generic throughout the process.

Despite Generic's stated turnaround time of 14 working days, my claim was only assessed after this period had elapsed. Throughout this delay, I made numerous follow-up calls and repeatedly requested updates on the status of my claim. I escalated the matter on several occasions, including to claims team leaders and specialist claims personnel, due to the lack of progress and communication.

What is particularly concerning is that despite my numerous engagements with Generic, no one was willing or able to verbally discuss the details of the claim assessment with me. I was not afforded an opportunity to understand the basis of the decision, ask questions, provide clarification, or engage in a meaningful discussion regarding the claim. Instead, after weeks of chasing for feedback and escalating the matter, I simply received an email after 10:00 PM advising me of the outcome.

Adding to my concern is the fact that the same procedure and diagnosis appear to have resulted in two differing outcomes, with no clear explanation being provided for the inconsistency. As a policyholder dealing with a serious cancer diagnosis, I would expect a transparent, fair, and consistent assessment process. The contradictory outcomes raise legitimate concerns regarding the accuracy and quality of the claims review process.

The handling of this matter has left me with the impression that decisions are being communicated without proper engagement, explanation, or consideration of the policyholder's right to understand and challenge the assessment. This approach is neither customer-centric nor aligned with the principles of Treating Customers Fairly (TCF).

I therefore request that Generic urgently:

Provide a detailed explanation for the failure to assess the claim within the stated 14-working-day turnaround period. Explain the basis for the differing outcomes relating to the same procedure and diagnosis. Provide a comprehensive breakdown of how the claim was assessed, including the specific policy provisions re**** upon. Review the claim and assessment process to determine whether the decision was app**** fairly and consistently. Arrange for a suitably qualified claims representative to discuss the matter with me directly and answer my questions regarding the assessment.

I have acted in good faith throughout this process and have made every reasonable effort to engage with Generic through the appropriate channels. Unfortunately, despite multiple calls, follow-ups, and escalations to team leaders and specialists, I remain without a satisfactory explanation for the outcome of my claim.

Should this matter not be resolved satisfactorily, I will have no alternative but to escalate it further to the relevant Ombudsman and regulatory bodies for independent review.

I trust that Kaelo/Generic will treat this complaint with the seriousness and urgency it deserves.