Medical aid refusing to pay claim

<p>I was admitted at Daymed hospital in Pietermaritzburg, KwaZulu Natal on the 26-01-2015 and was discharged on the 28-01-2016. The hospital got authorisation from my medical aid (nedgroup - Nedbank medical aid under Medscheme) for admission and the authorisation code was ***7.</p> <p> </p> <p><br />On the 17th of July 2015 i received an sms from Daymed hospital informing me that my medical aid rejected the claim of R17905.91, I immediately after that contacted the medical aid and spoke to a lady called Queen who advised me to forward the claim to Nedgroup again. I requested the documents from Daymed hospital which i forwarded to the medical aid.</p> <p> </p> <p><br />After weeks without any feedback from the medical aid, i sent an email asking them about update on my claim, they told me that they were still working on it, they will get back to me. at the end of the month (July 2015) I received a statement from my medical aid which said they were not processing the claim because the "claim was stale, claim details are either incomplete or incorrect, please submit and amend claim”, i was confused because i have never received any feedback from them about the claim until then, I then sent another email on the 8 September 2015 asking what was the meaning of the statement i received.</p> <p>On the 14 September 2015 i received an email from Nedgroup subject “Please accept my apology for the delayed response” the email continued “The claim for ****ed private hospital treatment date: 26/01/2015 for amount R17 905.91 has been received, however it has some missing information, please contact the hospital and ask them the resubmit a detailed invoice in order for us to process the claim” that email was from Sammy Kopa.</p> <p>Same day i contacted the hospital, got their email address and email them requesting the detailed invoice, i also added the medical aid on CC so that they will also get them where they were emailed back, so the hospital did send them the documents and I also sent them just to make sure that they did received them.</p> <p>On the 23 September 2015 i received an email from the medical aid hospital claims department saying that “Further feedback will be provided to you once the claim is finalised”</p> <p>On the 28 September 2015 i received another email informing me that they have sent an email to Daymed hospital asking them to amend the same documents they hospital sent.</p> <p>on the 29 September 2015 Daymed hospital sent the amended documents as requested by the medical aid, they also had me on CC</p> <p> </p> <p><br />In October 2015 I was admitted at Midlands hospital for two weeks, I was then unable to communicate with medical aid as we were using work email to communicate with them.</p> <p> </p> <p><br />I November I went on a maternity leave, but I was i was checking on my work email until they closed my work email.</p> <p> </p> <p><br />After seeing that the work email was not working anymore, I then contacted the medical aid using my personal email for feed back, the beginning of this year a lady called Queen from the medical aid contacted me and told me to forward the documents to another department (claims ***) she told me that is where they will process the claim.</p> <p> </p> <p><br />On the 10 April i received an email from the claims department which said i must follow up directly with the scheme, I rep**** telling them that i was referred to them by a lady called Queen from the scheme.</p> <p> </p> <p><br />After a few days I sent an email, just to get an update about the claim, on the day they sent me an automated reply which reads "This e-mail serves to confirm that we have received and are attending to your query.” with a query number, after a few days they said i must email a motivation letter for the claim, so i wrote the motivation letter and emailed it, but also after that email there was no feed back until i sent another email still asking them about the claim progress, </p> <p> </p> <p><br />and the next reply i received read as follows "Good day, This claim has been reprised by claims management and stale documentation has been completed.The claim has been rejected by the fund manager because the correct amended claim was submitted after the stale claim period.”</p> <p> </p> <p><br />So was surprised to hear that, as i was always asking them about the updates and feedback about this claim, I have emails proving that i was doing the follow up and supplying all the documents the asked for, but now they are saying they have rejected the claim, on what is that ruling based on,as they had given the hospital the authorisation and the hospital claimed.</p> <p> </p> <p><br />I would really appreciate it if you could help me to get clarification on this matter.</p> <p> </p> <p><br />my email address is: ***</p> <p>my contact cell number: ***</p> <p>my work number ***</p> <p>my work email is still down</p>