Declined Casuality claim

Good day Madeline,

Thank you for taking the time to bring this to our attention. 
  
We sincerely apologize for any inconvenience caused and the circumstances under which your Hellopeter posting has reached as we do take customer feedback seriously to improve our service and process to ensure that we meet our client’s expectations.
  
Kindly that authorization is granted based on the information that the hospital provides us when. When the hospital contacts us, they will inform us of the triage category that the patient is currently on. “Triage” means assessing of emergency patients by medical professionals at the emergency unit into categories of priority based on the urgency of treatment required founded on national/ international scales which includes time frames. The triage category may change based on changes in the condition of the insured or the actual diagnosis and treatment received. 

We grant the authorization based on the information that the hospital provides us with which included the patient's clinical and vital signs, unfortunately, an authorization for Admission cannot be granted if the information we receive from the hospital does not fall within the Orange or Red Triage Colour Category. Should the hospital confirm the Triage color to be Green, according to our policy schedule the condition will be covered under the day-to-day benefit being a normal GP consultation, medication, radiology, or pathology up to the respective cover limit. A Green Triage is Not covered under the emergency cover. When the patient is informed of the Triage color and benefit that the health insurance will provide, the choice is entirely up to the client as to whether they will continue with treatment at the hospital. 
Kindly note that diagnostic tests and pain control are a general exclusion under the in-hospital benefit. In order for Admission authorization to be granted we require the treatment plan from the hospital which will confirm active treatment to treat the confirmed condition and not observation. 
   
Certain terms and conditions are always applicable, and these are included in all policy documents before and during your experience with us. The terms and conditions of the policy must be adhered to and app**** fairly for all clients. We do have your best interests at heart, and we will assist with all we can in line with our terms and conditions. Please note we are governed by the FAIS Act and must apply the TCF policy to ensure all our clients receive fair service and cover.
 
We have acknowledged your complaint and we have escalated the matter to the relevant department. One of our consultants will be in contact with you to further discuss the matter at hand. 
Once again, we apologize for the inconvenience caused and we hope to restore the experience. 
                 
Kind Regards,
Oneplan