Formal Complaint Regarding PMB Coverage and Declined Procedure

I am writing to formally lodge a complaint regarding the handling of my recent request for a nasal endoscopic procedure. Earlier this year, my doctor submitted an application for this procedure, which was subsequently declined on the basis that it is a scheme exclusion under my current plan. Following this, I specifically requested that the matter be escalated to the medical advisor for review. The response I received stated that the procedure is “not PMB-related.” This determination is incorrect and unacceptable. The ICD-10 codes provided (H65.0 and J44.8) are classified as Prescribed Minimum Benefit (PMB) conditions according to the same system I use professionally. PMBs exist to guarantee that all members have access to essential healthcare services, irrespective of their chosen benefit option. The refusal to authorize this procedure has had a severe impact on my health and quality of life. I am now experiencing significant difficulties with daily activities, including loss of balance, symptoms consistent with Benign Paroxysmal Positional Vertigo (BPPV), and frequent collapses. Living alone exacerbates the risk, as I have no one to assist me during these episodes. This situation is both distressing and contrary to the principles of PMB coverage. I demand a thorough review of this case and an immediate reconsideration of the decision in compliance with PMB regulations. Failure to address this matter appropriately will leave me with no choice but to escalate the issue to the Council for Medical Schemes and other relevant regulatory bodies. I expect a written response within 7 working days outlining the steps Medshield will take to resolve this matter. Sincerely, Aphelele Member number: *** Contact: ***