EXCLUSION DESISION BASED ON WRONG DIAGNOSES

FORMAL COMPLAINT AND REQUEST FOR REVIEW OF BENEFIT EXCLUSION DECISION

Dear Sir/Madam,

I write to formally lodge a complaint regarding MAST Medical Aid's decision to exclude cover for the treatment of tonsillitis and any related conditions in respect of my son, Marcu Muller.

I believe this decision has been reached on an incorrect interpretation of his medical history and does not adequately consider the facts surrounding his current condition.

The exclusion appears to be based on two instances of treatment for tonsillitis prior to joining the scheme. These episodes occurred approximately five months apart and were isolated incidents rather than evidence of a chronic or ongoing condition. At no point was surgery recommended, nor was any specialist diagnosis made indicating a long-term medical problem.

The medical issues currently under investigation only arose following an illness on 3 March 2026. Since then, Marcu has undergone extensive treatment, including five courses of antibiotics and steroid medication, without any meaningful improvement. Due to the lack of response to treatment and uncer*****y regarding the diagnosis, we sought specialist medical opinions.

Importantly, both the initial General Practitioner and the first specialist subsequently proved to have incorrectly diagnosed the condition. As a result, we sought a second specialist opinion from Dr Black.

Following a comprehensive assessment, Dr Black advised that the underlying condition was not necessarily chronic tonsillitis as previously suspected and that a definitive diagnosis could only be made through examination under anaesthetic. Furthermore, on 19 May 2026, Dr Black diagnosed Marcu with glue ear (otitis media with effusion), a condition that had never previously been identified, diagnosed, or treated.

This diagnosis was entirely unknown prior to joining the scheme and could therefore not have been disclosed. It is difficult to understand how treatment for a newly diagnosed condition can be excluded on the basis of unrelated, isolated episodes of tonsillitis that occurred before membership commenced.

I am particularly concerned that MAST Medical Aid appears to have classified all current investigations and treatment as related to a pre-existing condition without adequately considering the subsequent specialist findings, the previous misdiagnoses, and the fact that a separate condition has now been identified.

Accordingly, I request that MAST Medical Aid urgently review this decision and provide:

1. A detailed written explanation of the reasons for the exclusion; 2. The specific policy provisions re**** upon in reaching this decision; 3. The medical evidence considered in determining that Marcu's current condition is related to a pre-existing condition; and 4. Confirmation as to whether the diagnosis of glue ear (otitis media with effusion) has been independently assessed and on what basis it is regarded as related to any alleged pre-existing condition.

Should this matter not be resolved satisfactorily, I intend referring the complaint to the Council for Medical Schemes for independent review, as I believe the current decision is unreasonable and not supported by the available medical evidence.

I trust that MAST Medical Aid will give this matter its urgent attention and I look forward to receiving a written response within the prescribed timeframes.

Yours faithfully,

Sunet Muller