COMPLAINT ABOUT TREATMENT RECEIVED FROM MEDSHIELD

This is Medshield slogan to their clients, I didn't experience any of these words.

"We believe prevention is better than cure and your well-being is obviously important to us."

Please advise whether you are a Trustee of the Medshield medical aid, if so I have a compliant with the service I have received during a recent and unforeseen hospitalisation and surgery I had to undergo. Of which some hospital bills were not paid from AOL or whereby in some instances they refused to authorised / pay tests and scans that were requested by the hospital.

When I made the change to your scheme I was advised that this is the best medical aid now it seems as more of exploiting members. With all this please you advise what can happen if someone do not receive treatment for a DVT or a PVT. I have been diagnosed with PVT not something I asked for, but well it occurred. Medshield advised that this is not a PMB as it is not a PE. So if a cloth moves what will be the implications thereof. I have contacted the chronic department to register this as a chronic condition, due to the medication, being warfarin and the continuous check of INR readings and dosages.

They advise that this does not constitute registration as a chronic condition. As warfarin is the most dangerous drug if not monitored correctly. So in your medical opinion please advise me what in your books constitute chronic?

Below correspondence with the complaints department for ease of reference.

Dear all

I'm writing to you all in sad regret of how I was treated by my medical aid during the whole process of being admitted and having to obtain authorisation.

When I joined Medshield, I was advised that this was the best medical aid for me, having to deal with Discovery which I clearly didn't approve of.

Starting my year I had no intention of being sick or even having to undergo a numerous of tests and procedures to be done on me.

I went in to see a doctor in casualty of which he advised that I obtain a bacterial infection of which oral medication was not gin to get rid of the bacteria. I went in with bleeding in the urine and excruciating pain to my abdomen and back.

The doctor wanted to administer a CT scan to be sure of what the course of all this would be and in so I requested for the scan to be done, even if it cost me. In so it was discovered that I have kidney stones. No one in my family has ever had this.

I was sent home on instruction of my medical due to the fact that they refused authorisation for the hospitalisation. In agony I left the hospital with oral medication which were prescribed to me.

A day later I was contacted by a Urologist, who specialises in infections and he advised that I would need to come in admission. As a fool I went to the hospital, and had to return home again as the underwriters decided that due to my medical aid membership being thus new that I needed to provide them with all my GP records within the 12 month period to proof that what is busy transpiring is not an existing condition.

I have given them all tis information and based on the Urologist contacting the medical aid himself and explaining his concerns were authorisation granted.

A week after being discharged, I've experienced some complications and went to see my GP, of which he advised that as per his conclusions I will have to go back to the hospital for readmission. I was than readmitted to hospital.

What upsets me the most is that the medical refuse to grant permission for these doctors to help and assist me in the way they knows best. My doctor requested for another CT Scan to be performed to conclude his findings, and the medical aid advised radiology that if it is not PE (Pulmonary Embolism) THEY WILL NOT PAY FOR THE SCANS REQUESTED FROM THE MEDICAL PRACTITIONERS.

So, in conclusion the reason for the specialist requesting for these scans if to 100% confirmed that the blood cloth that was busy forming in my veins was not obstructing any passage to my lungs.

At this current moment, I have been diagnosed with PVT, which to me is just as dangerous as any other thrombosis found in any part of the body. And refusal to grant authorisation for any medical practitioner to perform his work properly.

I am deeply disappointed in the medical aid and treating me as if I planned to be sick.

My 2018, and my hopes for this year was not to be sick, but to fulfil my obligations and go back to school.

I am currently on WAFARIN, in order to dissolve the cloth. I have to undergo numerous of blood tests which are being administered by LANCET INR CLINIC, which I believe they will refuse to pay this as well.

I have to attend follow-up consultations with these specialists again to do a scan again for them to obtain knowledge of cer*****y on whether this cloth is dissolving or not and to track its movements as it dissolves.

So, what this conclude is that we as consumer's will pay these schemes and when we do need their assistance in our time of need planned or unplanned we have to be half dead first before anything or authorisation may be granted, which to me is not fair.

Please advise to me urgently on this matter as I would like to report this lack of professionalism and peoples health to the medical board as this is not expectable to me.

IN A NUTSHELL. WHAT IF I HAD DIED WHILST PEOPLE AND UNDERWRITERS WERE TRYING TO REFUSE ME AUTHORISATION AND TREATMENT?

Also, if a person is hospitalised, doesn't all procedures gets covered under your hospitalisation benefit, PMB. Why would my medical benefits be exhausted for procedures that happened during my hospital stay?

I WOULD LIKE TO KNOW YOUR OPINION AND VIEWS ON THIS AS SOON AS POSSIBLE.

Response from Medical Aid Good day

With reference to your enquiry regarding: 120318QNJ3LZ

Membership number: ********** 8792

Medshield Medical Scheme has acknowledged your complaint and would like to thank you for bringing your concerns to our attention.

With reference to the authorisation request for admission date 30/01/2018 for dependant Louisa Lucinda Annelize. It should be noted, upon receipt of this authorisation request, it was pended for a non-disclosure process that needs to be followed. It should be noted, for any member/s that have joined the Scheme within the last 12 months, a non-disclosure process is followed. This is a standard process for all authorisation requests for members that are on the Scheme for less than a year. An investigation into a non-disclosure does not imply that your authorisation will be declined.

As per Scheme records, the member's joined and benefit date with the Scheme is 01/12/2017, hence the non-disclosure process.

It should be noted, our hospital department (MSO - Medical Services Organisation) sent the necessary forms to the member¿s doctors for clinical information. Upon receipt of all the necessary clinical information this request was reviewed and approved.

With reference to the authorisation request for admission date 23/02/2018 for dependant Louisa Lucinda Annelize. MSO received a call from the Hospital requesting an authorisation for Dependent 00. The patient was admitted at the Netcare Waterfall City Hospital under the care of Dr MF Suliman on the 23/02/2018. The necessary information was loaded and the authorisation was approved accordingly.

With reference to the authorisation request for the scans dated 26/02/2018. It should be noted, subsequent scans were done on 30/01/2018 and 13/02/2018 and the scan request for the 26/02/2018 was for R24000, which could not be approved as member had insufficient specialised radiology benefits available.

With reference to the follow up blood tests and scans to be done out of hospital. Kindly be advised, all out of hospital claims are payable from the member's available day to day benefit. As per scheme records, your day to day benefit is exhausted, hence this will need to be self-funded.

It should be noted, only your first admission was a PMB admission, hence accounts were paid accordingly. If a member or his/her dependants are hospitalised, all accounts are payable from the Overall annual limit(OAL), with the exception for specialised radiology, these are payable from the specialised radiology limit of R8000.00, unless proven to be PMB, will pay from OAL.

We trust you find the above in order and sincerely do apologise for the delay.

On behalf of the Scheme, I unreservedly convey our apologies to you for any misunderstanding, frustration and inconvenience experienced. We would further like to provide you with assurance of Medshield's commitment to improved service delivery as you are an important partner to our Scheme.

Should you require any further assistance please contact the Medshield Medical Scheme Contact Centre on ********** . Yours sincerely Rehna Perumal

Correspondence back to Medical Aid and since no responses again. Good day Please note that the information stipulated below is incorrect as this was 17598, as indicated by Radiology. the scan request for the 26/02/2018 was for R24000, which could not be approved as member had insufficient specialised radiology benefits available. Also, please advise what do you stipulate as PMB. As far as im concern being diagnosed with PVT (portal vein thrombosis) as serious as a PE or DVT. The nature of this condition is that you dealing with a cloth, a cloth which can move either way, heart, lungs or brain if not detected at an earlier stage.

So in your medical opinion (not sure what your profession) if you a medical practitioner or a sister, please advise me on PVT and how serious the nature of a cloth can be and if this doesn't qualify as a PMB?

So if you can for one second, place yourself in my situation if it was you or any of your family members in a similar situation how would you have reacted towards this?