Pathetic service

Dear Sonto,

Thank you for taking the time to bring this to our attention. 
          
From the outset, we sincerely apologize for the inconvenience caused by this ordeal and for all that you have been through. We do take customer feedback seriously to improve our service and process to ensure that we meet our client’s expectations as we do have your best interest at heart. 

Kindly note when the hospital contacts us, they will inform us of the triage category that the patient is currently on. “Triage” means assessing 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 change in the condition of the insured or the actual diagnosis and treatment received.

Records on our system confirm that the Casualty unit triaged you as yellow, based on this triage we could not grant authorization for the Casualty benefit, however, GP and  Radiology funds were loaded for you to seek medical assistance under the day-to-day benefit.

We grant the authorization based on the information that the hospital provides us with which includes the patient's clinical and vital signs, unfortunately, 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 colour to be Green or Yellow, 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 limits. A Green or Yellow Triage is Not covered under the emergency cover. 

 

When the patient is informed of the Triage colour 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 we may review the claim based on a confirmed diagnosis and a detailed invoice. You are welcome to send this information to *** with your policy number in the subject line and we will review the information. 

  
We have acknowledged your complaint and we have escalated the matter to the relevant department. One of our Clinical Risk Consultants will be in contact with you to further discuss the matter at hand in the hopes of providing clarity on the above matter. 

                  

Kind Regards,

Oneplan