Not honouring the their terms and conditions or embracing the spirit of legislation nor upholding the principles of TCF

On Sunday, 15 December 2024, I slipped on a stair at home around 5:00am and I fell on my buttocks which left me in excruciating pain. I called Momentum around 6:30am and the consultant advised me to go to a hospital and call back for authorisation.

I went to a private hospital around 7:30am on the above date and Momentum provided authorisation for treatment in the ER unit.

The ER doctor examined my sacral area and when he had pressed by my tailbone, it was excruciatingly painful. Subsequently, an x-ray was done and I was given an injection for the unbearable pain. The doctor confirmed per the x-ray, the good news is there hasnt been any fracture or damage to the bones but there is a lot of tissue and ligament damage around the tailbone. He mentioned it would take couple of weeks to heal. The doctor then prescribed pain medication and laxatives to soften the stool and I paid cash for this medication at Clicks as the staff member at the hospital's pharmacy mentioned my plan does not cover medication.

The next day, Monday, 16 November 2024, I continued to experience excruciating pain in my sacral area after the injection wore off. I booked my off from work and I managed to drive myself to a network GP and I explained the events of Sunday, I also explained that I had fainted earlier in the morning and I was experiencing bouts of hot flushes. The doctor reviewed the x-ray and documents from the hospital. He also confirmed it was also noted that it was required that I received anti-inflammatories, however, this was not noted on the script when I had gone to purchase the medication at Clicks. In any case, the doctor provided me with pain and anti-inflammatory medication which i was grateful for.

On Tuesday, 17 November 2024, I found the pain had became unbearable, I could not stand upright, sit, nor walk. I was up from 2:00am in pain while heavily drugged on pain medication. I also had another incident where I felt I was about to pass out, but I quickly got myself to bed and turned on my AC. After feeling the sacral area with my hand, I observed there was a huge bump which was extremely sensitive and painful. I then took a photo of it with my phone and I realised that it may be a boil/cyst thats covering/blocking the entrance.

I managed to muster up the strength and will to drive myself to a network GP and after showing him the photo, he mentioned it is a perianal abscess and it requires hospital admission as there isnt anything a GP could do.

Following the above, I contacted Momentum on the same day and explained the sequence of events from Sunday. The consultant mentioned I should return back to the hospital and authorisation will be given, she asked if I would want to take the reference number for the call but I declined as I took it in good faith that she has acted with due care, skill and diligence as an advisor and provided me with information which true.

After driving myself in sheer agony to the hospital, the hospital clerk and myself then spoke to another consultant at Momentum who was very helpful, but at the same time, she explained that authorisation cannot be given if we are unable to prove the current issue (perianal abscess) is linked to the fall on Sunday. The consultant therefore requested Sunday's injury report and x-ray report for review by the case manager before a decision could be made.

After this was reviewed by them, the consultant confirmed that authorisation for treatment in the ER unit has been granted (auth ***)

The ER doctor who saw to me enquired on the issue and I explained that on Sunday I fell on the edge of a stair and hurt my tailbone area, I explained that I was in ER on Sunday and what were the findings and treatment administered. I further went on to explain that following Sunday, I did not receive any reprise from the pain and I have not passed stool even though the ER doctor on Sunday prescribed laxatives. I mentioned there is now an abscess that has formed where I got hurt and it has now ruptured whilst driving to the GP and hospital (I could feel my underwear had become wet at the back). The doctor briefly had a look and confirmed it is a ruptured perianal abscess. He mentioned that he could give me antibiotics and I could leave or I could get admitted. As a layman, I do not understand the implications of such decision so the doctor went on to do blood tests and also administer pain meds and antibiotics through 3 IV drips.

After the blood results came back, the doctor confirmed the infection level is very high and he will call Momentum for admission.

To my horror, the hospital clerk came back to me stating Momentum has not granted authorisation as my plan does not cover perianal abscess treatment; and if I am to be admitted, it would be on a cash basis. As I coud not afford this, I disappointedly made my way home, with pus and blood oozing onto my underwear and pants.

Following the above, I ask that Momentum confirm the following to me in writing:

1. Considering you granted authorisation for treatment in the ER facility on Tuesday, by virtue of this, one can conclude that I have satisfied my burden of proof that the current issue (perianal abscess) is as a result of the covered event which occurred on Sunday (Accident).

Should you wish to dispute this, then I ask that you review the call recording from the hospital to you wherein your consultant explained that authorisation will be given if we can show the current issue is due to the fall on Sunday.

2. Under which benefit was the above authorisation on Tuesday administered, Accident cover or Emergency cover? Please provide supporting reasonings.

3. On the presumption that it was under the Accident benefit, the benefit allows for treatment in a Casualty unit and if serious, it allows for in-hospital treatment (admission).

Why was admission not granted and the condition itself was used as a deciding factor? On this basis, authorisation for ER treatment should not have been granted as well as medical insurance and more especially my plan type, does not cover illness or diseases. I cannot see you doing it as a gesture of goodwill.

4. If you accepted authorisation on Tuesday for treatment in the ER unit, you have thus followed your benefits/claims administration process and satisfied yourselves that my claim meets the terms and conditions of the policy wording and there are applicable benefits due. So again, why was I not allowed admission under the Accident benefit?

5. Why is medication not covered? I have paid cash for this on Sunday, drove myself while heavily medicated from ER to Clicks to get the medication.