1 reviews | Active since Feb 2012
Rejected Emergency Claims
I have really had it with you rejecting claims. I took my wife to Netcare Pretoria East Hospital (Emergency Ward) with a suspected fracture at night. I paid R1000 in fees as these would come off day to day benefits. Only you know why, anyway I was content to pay this and never claimed from you. Afterwards I received a bill for the x-rays which were done and the crutches she got as she couldn't walk. I sent you these claims listed under claim number: ********** 6 and ********** 7 which you have rejected. Now my question is what is listed as an emergency at medshield????? So you tell me I can be involved in an accident and be expected to pay for x-rays???? who knows I will probably have to pay the whole hospital bill. How is that day to day????
Number 2, I am diagnosed with 2 chronic conditions High blood pressure and cholesterol. You make me pay a co-payment of R50 for the high blood pressure medication which costs R120???? My subscriptions are R2844/month and you tell me you cannot pay R120 a month??? Then you don't want to pay for the cholesterol medication which costs R50 as well. Like is this some kind of joke???
What the hell do the monthly subscriptions pay for??? Clearly you don't pay for emergencies and you don't pay for chronic conditions. What is the medical aid for??? Really considering looking at other medical as I'm really scared, God forbid I have to go into hospital for some life threatening accident or illness.
Good day,
Medshield Medical Scheme has acknowledged your complaint and is currently investigating.
Kindly note that your concerns have been prioritised and feedback will be provided within 5 working days.
Yours sincerely,
Medshield
Good day,
Medshield Medical Scheme has acknowledged your complaint and is currently investigating.
Kindly note that your concerns have been prioritised and feedback will be provided within 5 working days.
Yours sincerely,
Medshield
Good day
With reference to your Hello Peter Complaint received on the 13/10/2017.
With reference to the appliance account for treatment date 14/09/2017.
Kindly note, the above-mentioned account has been processed in accordance to scheme rules and will be paid to the provider within our next payment run.
With reference to the account for x-rays, dated 14/09/2017.
Kindly be advised, this account has been in rejected in accordance to scheme rules as benefit limit exceeded.
With reference to your chronic medications. We have been advised accordingly by our chronic department:
Kindly be advised, the Medshield MediValue option utilizes the restrictive formulary. A 40% out of formulary co-payment will be applicable if medication is used that does not fall within the restrictive formulary. MPL (generic price list) co-payments might also be applicable.
Regarding the cholesterol medication:
Dynator 20mg was previously declined twice as the member does not meet Scheme’s funding criteria.
The Scheme’s policy for the treatment of Hyperlipidaemia is based on the government treatment algorithm as well as prevailing State practice.
The condition of Hyperlipidaemia was declined since a risk assessment was done taking into account all information sent to us. The patient did not meet the risk criteria as set out by the government algorithm that defines funding obligations for medical schemes.
This was confirmed with the treating provider as well.
Regarding the Hypertension medication:
Pearinda plus 30 per month is not within the restrictive formulary that the option utilizes and therefore the 40% out of formulary co-payment is applicable.
We have contacted the provider and she was more than willing to prescribe and in formulary alternative namely Enap Co 20mg 30 per month that will not attract any co-payment.
We trust you find the above in order.
Good day
With reference to your Hello Peter Complaint received on the 13/10/2017.
With reference to the appliance account for treatment date 14/09/2017.
Kindly note, the above-mentioned account has been processed in accordance to scheme rules and will be paid to the provider within our next payment run.
With reference to the account for x-rays, dated 14/09/2017.
Kindly be advised, this account has been in rejected in accordance to scheme rules as benefit limit exceeded.
With reference to your chronic medications. We have been advised accordingly by our chronic department:
Kindly be advised, the Medshield MediValue option utilizes the restrictive formulary. A 40% out of formulary co-payment will be applicable if medication is used that does not fall within the restrictive formulary. MPL (generic price list) co-payments might also be applicable.
Regarding the cholesterol medication:
Dynator 20mg was previously declined twice as the member does not meet Scheme’s funding criteria.
The Scheme’s policy for the treatment of Hyperlipidaemia is based on the government treatment algorithm as well as prevailing State practice.
The condition of Hyperlipidaemia was declined since a risk assessment was done taking into account all information sent to us. The patient did not meet the risk criteria as set out by the government algorithm that defines funding obligations for medical schemes.
This was confirmed with the treating provider as well.
Regarding the Hypertension medication:
Pearinda plus 30 per month is not within the restrictive formulary that the option utilizes and therefore the 40% out of formulary co-payment is applicable.
We have contacted the provider and she was more than willing to prescribe and in formulary alternative namely Enap Co 20mg 30 per month that will not attract any co-payment.
We trust you find the above in order.
Good day
With reference to the above, kindly refer to the MediValue brochure on page 18:
General radiology is subject to day to day limit. Also with reference to the scheme rules, kindly make reference to the Medshield Medical Scheme website.
Good day
With reference to the above, kindly refer to the MediValue brochure on page 18:
General radiology is subject to day to day limit. Also with reference to the scheme rules, kindly make reference to the Medshield Medical Scheme website.
Good day
Kindly be advised, "in hospital" refers to when a patient has be admitted to hospital. With reference to services rendered to a patient in casualty and then sent home - these are payable from the member's available day to day benefit. As per Scheme records, all accounts received for the services rendered in casualty for treatment date 14/09/2017 is non-pmb. It should be noted, the Scheme got in contact with the radiologist in question who confirmed there was no fracture only soft tissue injury and swelling. Kindly be advised this is not classified as PMB.
Good day
Kindly be advised, "in hospital" refers to when a patient has be admitted to hospital. With reference to services rendered to a patient in casualty and then sent home - these are payable from the member's available day to day benefit. As per Scheme records, all accounts received for the services rendered in casualty for treatment date 14/09/2017 is non-pmb. It should be noted, the Scheme got in contact with the radiologist in question who confirmed there was no fracture only soft tissue injury and swelling. Kindly be advised this is not classified as PMB.