REFUSE TO SETTLE PMB

Medshield did reply on my complaint regarding the non payment of a PMB and as I predicted, the member will always be on the short end. This time round i just received another excuse why the claim could not be processed as a PMB case.

Medshield indicated that the account submitted for a CT scan was declined by a medical adviser due to "procedure not a PMB eligible code". The claim was reviewed and declined on 25/02.

What has happened to my appeal and specialists motivation which was submitted on 16/07. In which he stated that it should be treated as a PMB. According to their latest answer I can only assume that this appeal and morivation was just ignored and never taken into consideration, as they indicated that the claim was declined on 25/02.

When i contacted Medshield the first time round I was informed that it was declined due to insufficient funds for radiology.

When I contacted the radiologist I was informed that the claim was declined because the scan could not indicate the reason for the anemia and that it is not a life threatning decease.

With all these different answers provided it seems to me that it is all excuses not to settle an account and a medical adviser can over ride a specialist' s motivation.

What has happened to the so called 100% hospital benefits and unlimited PMB benefit Is this all a hoax? Up to date I am not satisfied with the medical aid and its unhelpful approach on claims and cases and reasons provided for declining, each and every consultant gives a different answer and appeals are just a waist of time