AM
Annerie M
1 reviews | Active since Oct 2012
20 Nov 2023, 09:12
special conditions number 7 - REJECTED CLAIM
Not really happy with this insurance. I have multiple pets insured on the Classic Plan with the excess buster. In total I had 4 Pets on the Classic.. this is expensive. I dont just do claims but when i do it is totally needed. Recently i submitted a claim with got rejected. This was for in hospital treatment as my pet was admitted to the hospital. The invoice total was for R2900.00 and they just rejected it. In the hospital admission policy they state that Illness is covered under the Hospital Matrix, this means unforseen sickness, Illness or Disease originating during the period of insurance. The reason my pet was admitted was because he was eating his own skin off his body, so bad he lost hair growth.
Now this is not my first rejected claim, Ive had many.
The insurance is more than happy to take your money on a monthly basis but they will not pay out for hospital claims arising from unforseen sickness!!! They just decline and reject left and right.
Oh and just to note, on special conditions number 7. Should a diagnostic procedure result in a confirmed diagnosis and treatment plan the cost of the procedure will be covered under the hospital admission limit??? then why are you rejecting my claim when a confirmed diagnosis was made????
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Replies (5)
Oneplan Insurance's replyOfficial
20 Nov 2023, 13:20Dear Annerie,
Thank you for taking the time to bring this to our attention.
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 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. We do have your fur-babies best interest at heart and wish that he has a speedy recovery.
We have attempted to contact you on the listed number; however, it was to no avail.
Kindly note that according to the clinical notes we received from the Vet, it confirms that your fur-baby was in-hospital for diagnostic tests only and medication was dispensed.
For a claim to be reviewed under In-Hospital Admission we will require a completed claims form from the vet and the invoice must reflect details of an In-Hospital corrective procedure. If the invoice does not reflect a corrective procedure, it will be covered under the Casualty benefit up to the respective cover limits as this is in line with our policy terms and conditions. All in-hospital claims must meet our admission matrix which is found in your policy schedule.
Regarding the medication provided for your fur-baby, this falls under the Casualty benefit up to a specific cover limit and Monroe is entitled to 4 Casualty visits per year. Unfortunately, as all the Casualty benefits have been exhausted for Monroe, we were unable to process this claim under the Casualty benefit. There are annual cover limits on all our cover types. Once the annual cover limit has been exceeded, the cover limit benefit will renew on the anniversary of your policy.
We have attempted to contact you on the listed number; however, it was to no avail.
Kindly note that according to the clinical notes we received from the Vet, it confirms that your fur-baby was in-hospital for diagnostic tests only and medication was dispensed.
For a claim to be reviewed under In-Hospital Admission we will require a completed claims form from the vet and the invoice must reflect details of an In-Hospital corrective procedure. If the invoice does not reflect a corrective procedure, it will be covered under the Casualty benefit up to the respective cover limits as this is in line with our policy terms and conditions. All in-hospital claims must meet our admission matrix which is found in your policy schedule.
Regarding the medication provided for your fur-baby, this falls under the Casualty benefit up to a specific cover limit and Monroe is entitled to 4 Casualty visits per year. Unfortunately, as all the Casualty benefits have been exhausted for Monroe, we were unable to process this claim under the Casualty benefit. There are annual cover limits on all our cover types. Once the annual cover limit has been exceeded, the cover limit benefit will renew on the anniversary of your policy.
Please be aware that although we have a confirmed diagnosis for your pet, the services listed on the invoice only include diagnostic tests and medication and not any In-Hospital corrective procedures. This is why the claim was rejected under the in-hospital benefit.
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, please note that this is by no means a ploy to refuse payment of the claim. We do have your fur-babies 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.
Once again, we apologize for any inconvenience caused and we hope the above brings clarity on the matter.
Kind Regards,
Oneplan
Oneplan Insurance's reply20 Nov 2023, 13:20
Official
Dear Annerie,
Thank you for taking the time to bring this to our attention.
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 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. We do have your fur-babies best interest at heart and wish that he has a speedy recovery.
We have attempted to contact you on the listed number; however, it was to no avail.
Kindly note that according to the clinical notes we received from the Vet, it confirms that your fur-baby was in-hospital for diagnostic tests only and medication was dispensed.
For a claim to be reviewed under In-Hospital Admission we will require a completed claims form from the vet and the invoice must reflect details of an In-Hospital corrective procedure. If the invoice does not reflect a corrective procedure, it will be covered under the Casualty benefit up to the respective cover limits as this is in line with our policy terms and conditions. All in-hospital claims must meet our admission matrix which is found in your policy schedule.
Regarding the medication provided for your fur-baby, this falls under the Casualty benefit up to a specific cover limit and Monroe is entitled to 4 Casualty visits per year. Unfortunately, as all the Casualty benefits have been exhausted for Monroe, we were unable to process this claim under the Casualty benefit. There are annual cover limits on all our cover types. Once the annual cover limit has been exceeded, the cover limit benefit will renew on the anniversary of your policy.
We have attempted to contact you on the listed number; however, it was to no avail.
Kindly note that according to the clinical notes we received from the Vet, it confirms that your fur-baby was in-hospital for diagnostic tests only and medication was dispensed.
For a claim to be reviewed under In-Hospital Admission we will require a completed claims form from the vet and the invoice must reflect details of an In-Hospital corrective procedure. If the invoice does not reflect a corrective procedure, it will be covered under the Casualty benefit up to the respective cover limits as this is in line with our policy terms and conditions. All in-hospital claims must meet our admission matrix which is found in your policy schedule.
Regarding the medication provided for your fur-baby, this falls under the Casualty benefit up to a specific cover limit and Monroe is entitled to 4 Casualty visits per year. Unfortunately, as all the Casualty benefits have been exhausted for Monroe, we were unable to process this claim under the Casualty benefit. There are annual cover limits on all our cover types. Once the annual cover limit has been exceeded, the cover limit benefit will renew on the anniversary of your policy.
Please be aware that although we have a confirmed diagnosis for your pet, the services listed on the invoice only include diagnostic tests and medication and not any In-Hospital corrective procedures. This is why the claim was rejected under the in-hospital benefit.
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, please note that this is by no means a ploy to refuse payment of the claim. We do have your fur-babies 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.
Once again, we apologize for any inconvenience caused and we hope the above brings clarity on the matter.
Kind Regards,
Oneplan
AM
Annerie M's updateReviewer Update
20 Nov 2023, 14:41This cut out is from the policy wording.
Thus meaning that my cat has a Disease/Sickness as described on the treatment plan/ hospital report.
The following cut out is from his diagnosis.
Following is an insert of a blog post - https://blog.oneplan.co.za/pet-insurance-that-covers-pre-existing-conditions/ for ILLNESS COVER
Following is from my POLICY SCHEDULE.
Illness/ disease cover????
Are you honestly rejecting my claim for my pet on the illness benefit from the Hospital cover, when it is clear that Allergic skin is a Disease/ Illness that needs medication for the rest of his life???
As per multiple inserts from your blogs, websites and policy working this is supposed to be paid from that benefit.
Hope to hear back from you soon in this regard as this coming Feb 2024 I will be with you guys for 2 years. That is a total of R32 685.00 I have paid in premiums over 2 years and the only claims I have submitted and you have paid for amounted to R16 305.05 for a total of 8 pets that I had listed.
Unfortunately I had some pets pass away as in Katryn and Laika, Zues has a new home that’s why he was taken off the insurance.
I have paid more on premiums than what you have covered as of FEB 2024!!
Thanks,
From: *** <***>
Sent: Monday, November 20, 2023 8:53 AM
Sent: Monday, November 20, 2023 8:53 AM
Dear Annerie Meyer,
I trust that you are well.
We regret to inform you that your recent claim for Monroe has been rejected.
This is because the invoice reflects a consultation, medication and diagnostic procedures. For a claim to be considered under the Hospital Admission benefit, the invoice must reflect details that will be assessed according to the Admission Matrix. No treatment that meets Admission Matrix requirements occurred and for this reason, the claim unfortunately cannot be considered under the in-hospital benefit.
Herewith your Repudiation Letter and the Complaints Resolution Policy for your perusal.
Kind Regards,
Heather Webster
Claims Consultant
E: ***
Your Insurance Family,
Oneplan
AM
Annerie M's update20 Nov 2023, 14:41
Reviewer Update
This cut out is from the policy wording.
Thus meaning that my cat has a Disease/Sickness as described on the treatment plan/ hospital report.
The following cut out is from his diagnosis.
Following is an insert of a blog post - https://blog.oneplan.co.za/pet-insurance-that-covers-pre-existing-conditions/ for ILLNESS COVER
Following is from my POLICY SCHEDULE.
Illness/ disease cover????
Are you honestly rejecting my claim for my pet on the illness benefit from the Hospital cover, when it is clear that Allergic skin is a Disease/ Illness that needs medication for the rest of his life???
As per multiple inserts from your blogs, websites and policy working this is supposed to be paid from that benefit.
Hope to hear back from you soon in this regard as this coming Feb 2024 I will be with you guys for 2 years. That is a total of R32 685.00 I have paid in premiums over 2 years and the only claims I have submitted and you have paid for amounted to R16 305.05 for a total of 8 pets that I had listed.
Unfortunately I had some pets pass away as in Katryn and Laika, Zues has a new home that’s why he was taken off the insurance.
I have paid more on premiums than what you have covered as of FEB 2024!!
Thanks,
From: *** <***>
Sent: Monday, November 20, 2023 8:53 AM
Sent: Monday, November 20, 2023 8:53 AM
Dear Annerie Meyer,
I trust that you are well.
We regret to inform you that your recent claim for Monroe has been rejected.
This is because the invoice reflects a consultation, medication and diagnostic procedures. For a claim to be considered under the Hospital Admission benefit, the invoice must reflect details that will be assessed according to the Admission Matrix. No treatment that meets Admission Matrix requirements occurred and for this reason, the claim unfortunately cannot be considered under the in-hospital benefit.
Herewith your Repudiation Letter and the Complaints Resolution Policy for your perusal.
Kind Regards,
Heather Webster
Claims Consultant
E: ***
Your Insurance Family,
Oneplan
AM
Annerie M's updateReviewer Update
20 Nov 2023, 15:01This just proves that ALL INSURANCE COMPANIES will look for any and all reason not to pay for anything. Even when the policy wording etc states that ILLNESS/ DISEASE is covered under the Hospital benifit.
AM
Annerie M's update20 Nov 2023, 15:01
Reviewer Update
This just proves that ALL INSURANCE COMPANIES will look for any and all reason not to pay for anything. Even when the policy wording etc states that ILLNESS/ DISEASE is covered under the Hospital benifit.
AM
Annerie M's updateReviewer Update
21 Nov 2023, 09:16Kindly note that telephone communication will not be done anymore, everything must be done via email. Because i am upset doesnt give your staff the right to raise their voice in order to talk over me.
As i just told the staff member that called me, One plan is contradicting themselves, my cat was diagnosed with a disease after a diagnostic procedure, this falls under the specified "Special Conditions" cover from hospital.
Now you want to tell me that his chronic medication comes from the pet med savings? Thats bull!!
ILLNESS/DISEASE is unforseen, there is even a Illness Admission that gets covered from the hospital benefit.
Under the common signs that a PET IS ILL you noted a few items to look out for of which "Hairloss or Itchy Skin" is part of.
You can tell me one thing and then say another.
As i just told the staff member that called me, One plan is contradicting themselves, my cat was diagnosed with a disease after a diagnostic procedure, this falls under the specified "Special Conditions" cover from hospital.
Now you want to tell me that his chronic medication comes from the pet med savings? Thats bull!!
ILLNESS/DISEASE is unforseen, there is even a Illness Admission that gets covered from the hospital benefit.
Under the common signs that a PET IS ILL you noted a few items to look out for of which "Hairloss or Itchy Skin" is part of.
You can tell me one thing and then say another.
AM
Annerie M's update21 Nov 2023, 09:16
Reviewer Update
Kindly note that telephone communication will not be done anymore, everything must be done via email. Because i am upset doesnt give your staff the right to raise their voice in order to talk over me.
As i just told the staff member that called me, One plan is contradicting themselves, my cat was diagnosed with a disease after a diagnostic procedure, this falls under the specified "Special Conditions" cover from hospital.
Now you want to tell me that his chronic medication comes from the pet med savings? Thats bull!!
ILLNESS/DISEASE is unforseen, there is even a Illness Admission that gets covered from the hospital benefit.
Under the common signs that a PET IS ILL you noted a few items to look out for of which "Hairloss or Itchy Skin" is part of.
You can tell me one thing and then say another.
As i just told the staff member that called me, One plan is contradicting themselves, my cat was diagnosed with a disease after a diagnostic procedure, this falls under the specified "Special Conditions" cover from hospital.
Now you want to tell me that his chronic medication comes from the pet med savings? Thats bull!!
ILLNESS/DISEASE is unforseen, there is even a Illness Admission that gets covered from the hospital benefit.
Under the common signs that a PET IS ILL you noted a few items to look out for of which "Hairloss or Itchy Skin" is part of.
You can tell me one thing and then say another.
Oneplan Insurance's replyOfficial
21 Nov 2023, 15:10Dear Annerie,
We apologize for any dissatisfaction you have experienced with Oneplan. We value your opinion and take customer satisfaction seriously.
Chronic medication is covered under the day-to-day benefit and will be assessed through the Pet Med Savings benefit.
Admission or hospitalization exclusively for diagnostic procedures, monitoring, and observing will not be covered under the in-hospital benefit, this will be covered under the Casualty benefit up to the respective cover limits.
Kindly note that this is a standard policy that applies to all our clients. We are governed by the FAIS Act and must apply the TCF policy to ensure all our clients receive fair service and cover.
Should you wish to escalate this further, if you believe that you have been treated unfairly, we encourage you to do so. We at Oneplan, pride ourselves on treating customers fairly and equitably. Our Complaints Department is an independent department dedicated to addressing concerns like yours.
Please send an email to *** to escalate your matter. Our Complaints Department will thoroughly investigate and respond accordingly.
Kind Regards,
Oneplan
We apologize for any dissatisfaction you have experienced with Oneplan. We value your opinion and take customer satisfaction seriously.
Chronic medication is covered under the day-to-day benefit and will be assessed through the Pet Med Savings benefit.
Admission or hospitalization exclusively for diagnostic procedures, monitoring, and observing will not be covered under the in-hospital benefit, this will be covered under the Casualty benefit up to the respective cover limits.
Kindly note that this is a standard policy that applies to all our clients. We are governed by the FAIS Act and must apply the TCF policy to ensure all our clients receive fair service and cover.
Should you wish to escalate this further, if you believe that you have been treated unfairly, we encourage you to do so. We at Oneplan, pride ourselves on treating customers fairly and equitably. Our Complaints Department is an independent department dedicated to addressing concerns like yours.
Please send an email to *** to escalate your matter. Our Complaints Department will thoroughly investigate and respond accordingly.
Kind Regards,
Oneplan
Oneplan Insurance's reply21 Nov 2023, 15:10
Official
Dear Annerie,
We apologize for any dissatisfaction you have experienced with Oneplan. We value your opinion and take customer satisfaction seriously.
Chronic medication is covered under the day-to-day benefit and will be assessed through the Pet Med Savings benefit.
Admission or hospitalization exclusively for diagnostic procedures, monitoring, and observing will not be covered under the in-hospital benefit, this will be covered under the Casualty benefit up to the respective cover limits.
Kindly note that this is a standard policy that applies to all our clients. We are governed by the FAIS Act and must apply the TCF policy to ensure all our clients receive fair service and cover.
Should you wish to escalate this further, if you believe that you have been treated unfairly, we encourage you to do so. We at Oneplan, pride ourselves on treating customers fairly and equitably. Our Complaints Department is an independent department dedicated to addressing concerns like yours.
Please send an email to *** to escalate your matter. Our Complaints Department will thoroughly investigate and respond accordingly.
Kind Regards,
Oneplan
We apologize for any dissatisfaction you have experienced with Oneplan. We value your opinion and take customer satisfaction seriously.
Chronic medication is covered under the day-to-day benefit and will be assessed through the Pet Med Savings benefit.
Admission or hospitalization exclusively for diagnostic procedures, monitoring, and observing will not be covered under the in-hospital benefit, this will be covered under the Casualty benefit up to the respective cover limits.
Kindly note that this is a standard policy that applies to all our clients. We are governed by the FAIS Act and must apply the TCF policy to ensure all our clients receive fair service and cover.
Should you wish to escalate this further, if you believe that you have been treated unfairly, we encourage you to do so. We at Oneplan, pride ourselves on treating customers fairly and equitably. Our Complaints Department is an independent department dedicated to addressing concerns like yours.
Please send an email to *** to escalate your matter. Our Complaints Department will thoroughly investigate and respond accordingly.
Kind Regards,
Oneplan