Formal Complaint Regarding Unjustified Rejection of Procedure Coverage and Co-payments

To: Medihelp Medical Aid Subject: Formal Complaint Regarding Unjustified Rejection of Procedure Coverage and Co-payments

Dear Medihelp Complaints Department,

I am writing to formally lodge a serious complaint regarding the way my recent medical situation and claim have been handled.

I am a paying member of Medihelp, contributing R7,362 per month, which amounts to approximately R88,344 per year. Given this significant investment, I reasonably expect comprehensive and fair medical cover when I am in need — which is currently the case.

Due to ongoing and severe pain in my left arm, I recently consulted an orthopedic specialist on 6 June 2025. He referred me for a sonar and X-ray, which revealed that the tendons in my left elbow require surgical intervention. The pain has become unbearable, and I currently have only 6–15% functional use of the arm, unable to lift even light items — including my own children. My right arm is now overcompensating, and I fear that it may soon suffer the same fate.

The specialist confirmed that cortisone injections are no longer a viable solution and that surgery is required to restore movement and prevent further damage. Despite this professional medical assessment, I was informed by Medihelp that:

You will not cover most of the procedure codes submitted by the orthopedic surgeon.

I must pay a R5,000 co-payment to the hospital.

I am further expected to pay R16,500 directly to the doctor.

Your reasoning is that the imaging results show “normal” findings.

With respect, this raises serious concerns. Why would a specialist recommend surgery based on “normal” results? Why am I, a loyal member contributing nearly R90,000 annually, being made to cover R21,500 out-of-pocket for a medically necessary procedure in a network hospital?

To make matters worse, you previously suspended my cover over R72 just three months ago, and now, when I need your support most, you are rejecting essential treatment. I am being forced to pre-pay for surgery while in debilitating pain, hoping that post-operative notes might convince Medihelp to consider reimbur*****t — which is neither acceptable nor ethical.

I hereby demand that this matter be resolved immediately. Specifically, I request that Medihelp:

Reassess and approve the orthopedic surgeon’s submitted codes;

Cover the full cost of the hospital and surgical procedure without requiring upfront payments;

Provide a clear explanation for the initial denial and inconsistent treatment of this claim.

If this issue is not resolved fairly and promptly, I will escalate the matter to the Council for Medical Schemes and other regulatory bodies. I am prepared to take this matter as far as necessary, including legal and public channels.

Please treat this matter as urgent and respond no later than 18 June 2025.

Sincerely, Henri Engelbrecht Medihelp Member Number: ***