Inconsistency on claims

In 2016 we were on momentum Custom Plan medical aid.I registered on the maternity plan which covers for 12 antenatal visits and 2 scans 2 pediatric visits for baby . All visit charges were paid to the gynae , no shortfalls experienced.The claims were covered from the major medical benefit. Later in the year we changed our plan to the Access plan with aim to accommodate our son and get more day to day GP visits however we seem to be paying more than what the medical aid itself covers.

As i am now pregnant , the access plan covers for Four antenatal visits and 2 growth scans.No cover for pediatric visits! More expensive option but less benefits !

The issue is that from these four antenatal visits from my current pregnancy , none of them were paid in full by momentum .It is frustrating to constantly inquire on rejected claims and we are constantly told that the codes need to be changed.My gynae is using right codes as communicated by momentum. Bear in mind that these are the same codes and amounts that were claimed during my 2016 pregnancy. ( These were paid in full) . There seem to be some sort of contradiction from momentum/No consistency . The doctor is using the right codes and nothing is been done or paid. we have been told to ask the doctor to resubmit and this has been done numerously . I am highly frustrated as now momentum has paid agreed scheme rates for some of the claims , what about the rest !.What about the shortfall amounts, I keep on receiving feedback that the doctor is charging above agreed rates /was the doctor not charging above agreed rates in 2016 , why were those payments paid in full. Currently we are due to be handed over to lawyers and the account is gaining interest. This obviously impacts negatively on our ITC record . To top my frustrations , momentum then says member is not liable for any shortfall amounts , How are we not liable when we receive a statement that shows that we are in arrears ? .If you have an agreement with a specialist and you see that they are charging above agreed rates why do u not liaise withe the doctor !very *********! I have emailed momentum numerously however this is not been resolved. two weeks ago i had to pay 650 cash to the gynae , the correct code was used , i then submitted the claim and only to get a response that we do not have day to day funds .How is this supposed to be paid from day to day funds account if it should be covered by the medical aid. Momentum medical aid is worth nothing, i wouldn't recommend it!, they promise good value for money. i haven't seen this at all instead this has just caused me more stress during my pregnancy. The very last thing that one wants to do is worry about finances during such times .