Rejected claim (Misleading information)

<p>Good day,</p> <p>Could you kindly help here,</p> <p><br />On Thursday (14 Oct) I made a search of primary access care GP on your network from the mobile app. Very sick to even drive far, I realized Dr Q Koben in Benoni (+-12km) was the closest since there are not GPs from your network in Kempton park (surprisingly). When I arrived at the doctor's premises I found out that he put a note that he has relocated to Medicross in Benoni effective 11 October. Eventually I went to Medicross looking to consult, the ladies on the front desk created a new pink file for me (after telling them i'm on the Access Primary option with momentum). SO then I assumed everything is ok. They gave me an immediate available doctor (Dr Botha) to attend to me. He performed procedures and after prescribed medicine to me that (knowing from the info I got from momentum that I can only get medicine by doctor's prescription), I went over to the Medicross clinic pharmacy and when the pharmacist punched my member number in their system they found out that I don't exist. The lady immediately called Momentum to find out what the issues was, and surprisingly she was told i'm on the Ingwe (not access, or maybe another name for Access) option and they don't cover pharmacies out of primary access network. I was very shocked and forced to use my last cash to pay for the prescription and the doctor's consultation bill as well which at the time I had only cash to pay for the prescription. </p> <p><br />When I first took out cover with you, the guy (MR ME MAKWELA 517541) who assisted me advised me that on day-to-day cover that I have only 10 GP visits per beneficiary per year and that those should be listed on Primary access network as providers, he also advised that I am only allowed to use my medical for only prescribed medicine at pharmacies and not covered for over the counter *. Now sadly it's a contradiction that I was denied medicine from prescription having been told that its not covered where else it was never mention that I had to only use special covered pharmacies. Medicross also upon registration saw that because i'm using Access option I'm covered hence they opened a pink file for me instead of a standard blue one. Another point to be taken here, * Out-of-network GP, casualty or after-hours visits. I'm aware that even if under any circumstances (that makes you decline cover after all my explanation and misleading information I got from your consultants) it's noted below from Sue's email that even if the provider is not on your network list, i'm covered once a year to go consult, meaning I should be covered for max R950 including medicine.</p> <p><br />Ultimatum;<br />Could you kindly refund my doctor and medicine charges including R50 bucks (phone charges) I had to pay for or otherwise cancel my membership (I'll move over to better provider) and refund my premium. I will even take it far by taking this to HelloPeter and further consulting with my lawyers who will be happy to help me any time.</p> <p> </p> <p><br />* Please refer email from Sue-Ann and take not on the last point.<br />Sue-Ann Spencer <SueAnn.Spencer@ momentum.co.za><br /> Oct 4 (11 days ago) <br /> <br /> <br /> <br />to me<br /> <br /> <br /> <br /> <br /> <br /> <br />Dear Mr K Thabe, </p> <p> </p> <p>Thank you for your time today and once again welcome to Momentum Health. There are a few important things that I would like to revisit on your medical aid. For your ease of convenience, I have outlined the important information below.</p> <p> </p> <p>You have selected the Access option with Momentum and we would like to make sure that you are aware of the benefits on this plan.</p> <p> </p> <p>The Access Option provides cover for hospitalisation at the Access Network of private hospitals. There is no overall annual limit for hospitalisation. For chronic treatment and day-to-day benefits, such as doctors’ visits or prescribed medicine, you must consult Access Primary Care Network providers.</p> <p> </p> <p>The Health Platform benefit provides cover for a range of preventative care benefits available from your Access Primary Care Network provider.</p> <p> </p> <p>If you need more day-to-day cover, you can make use of the HealthSaver. The HealthSaver is a complementary product offered byMomentum that lets you save for medical expenses.</p> <p> </p> <p>Cover While You are In-Hospital</p> <p> </p> <p>The Access option provides cover for hospitalisation and certain Specialised Procedures/Treatment. There is no overall annual limit on hospitalisation. Claims are paid up to 100% of the Momentum Health Rate.</p> <p> </p> <p>Under the hospitalisation benefit, hospital accounts and related costs incurred in hospital (from admission to discharge) are covered – provided that treatment has been authorised.</p> <p>Specialised Procedures/Treatment do not necessarily require admission to hospital and are included in the Major Medical Benefit – provided that the treatment is clinically appropriate and has been authorised.</p> <p> </p> <p>If authorisation is not obtained, a 30% co-payment will apply on all accounts related to the event and the Scheme would be responsible for 70% of the negotiated tariffs, provided authorisation would have been granted according to the rules of the Scheme. In the case of an emergency, you or someone in your family or a friend may obtain authorisation within 72 hours of admission.</p> <p> </p> <p>The Chronic Benefit</p> <p> </p> <p>The Chronic Benefit covers certain life-threatening conditions that need on-going treatment. On the Access Option, chronic benefits are available from the Access Primary Care Network. Chronic cover is provided for 26 conditions according to the Chronic Disease List, which forms part of the Prescribed Minimum Benefits. Chronic benefits are subject to registration and approval.</p> <p> </p> <p>The Day-to-day Benefit</p> <p> </p> <p>This benefit provides for day-to-day medical expenses, such as doctors’ visits, prescribed medicine etc. On the Access Option the day-to-day benefits are available from the Access Primary Care Network.</p> <p> </p> <p>GP Visits</p> <p> </p> <p>You have access to 10 visits per beneficiary. From the 11th visit onwards, you need to obtain authorisation and a R65 co-payment will apply.</p> <p> </p> <p>Dentistry</p> <p> </p> <p>Examinations, fillings and x-rays as per the list of tariff codes. One dental consultation is covered per year per beneficiary. You need to call us for pre-authorisation if you have more than 4 fillings or 4 extractions. Specialised dentistry is not covered on your option.</p> <p> </p> <p>Out-of-network GP, casualty or after-hours visits</p> <p> </p> <p>1 visit per beneficiary per year, subject to authorisation (You need to authorise within 72 hours of the consultation, otherwise a 30% co-payment will apply) is covered. You have a maximum of 2 visits per family per year. Limited to R950 per event and a 10% co-payment applies.</p>