Profmed Medical Scheme. There to help you or themselves?

One of the most unpleasant experiences I have ever experienced from a service provider, claiming to be a reputable company with crystal clear information and no illusions about their ethics... Think again. I was experiencing lower back pain, and was reffered to do MRI of lumbar spine.

I had contacted Profmed on 25 March 2024, who reffered me to pre-authorization dpt, who had indicated that they have now in 2024 released a new product which covers outpatient MRI/CT scans up to R6 0000. I said ok, what about shortfall as any scan would cost more... I was told it will be covered by Profmed with a 20% co-payment of total amount. I had booked MRI for the next day the 26th as an outpatient after being advised by Peofmed consultant. The next day prior to me doing the scan... Same story, with a separate consultant, "Profmed will cover the shortfall".

I do scan and then I am given a bill with shortfall included as all consultants now claiming they will only cover 80%, with a co- payment, of 20% up to a maximum of R6 000. I ask you... Does it make any sense?? No MRI/CT scan is below R10 000. What product are they really selling...?

After eventually getting hold of their supervisors, after many requests to escalate the matter, told they are meetings, etc. They said they will review audio of recorded conversation to clarify the matter... Subsequently, now they are claiming they said it will be covered by Gap cover. I do do not have gap cover. We had no discussion of such... We escalated to the supervisor's supervisor, Abigail, almost never available, but once they did get back to me it is now said that we spoke about gap cover... That discussion did not take place. I requested as the client, I too want recordings, as this now is becoming a he said/she said.... I am still awaiting for the recordings or even to hear it. First they said technical issues, then apparently they obtained recording but they cannot provide it to me.... Last week, many weeks later, I am told they must follow their internal processes. Me as the client is still waiting. I would like to take the matter forward to the FAIS ombud as here are my issues:

1. Producing a product that their own consultants are not trained about. 2. Providing mis-information to their clients and not taking responsibility of such. 3. Poor work ethic and principles. No communication or follow-up while being evasive, even though I try calling them on a daily basis, wasting our time and money even further. One consultant even said she is working from home? Isn't that nice... While we are all out there working paying an arm and a leg for such poor service while their employees are working from the comfort of their own home. 4. Is this a scheme/****? My shortfall was R2 000. Which may not be much at first glance... However, if you do the same to a thousand clients, that would be R2 million. Looking at the reviews, mostly poor, it is quite possible.

It is really sad that Profmed Medical Aid Scheme portrays themselves to be a good medical aid scheme to cater for professionals when they themselves are not professional... It says a lot. National Health Insurance (NHI)? Most people said no... But currently we are being ****** by people in the name of medical insurance! I am still awaiting to be contacted by the superiors, superior or any management level employee to contact me as authorization dpt is a joke... Made me seriously consider continuing with them or another medical aid scheme who has a better reputation... Please may you as the reader think twice before Profmed deals with you too🙏🏽