Non Payments to providers
<p>I have had it with Selfme Medical aid not paying medical bills. I am on the Selfnet scheme and I go to Doctors that are contracted in. In January 2017 I could not see the doctor as he was on leave and went to my GP that is not contracted in to Selfnet and paid him. He did blood tests and now the Medical aid does no pay for it as he was not a Doctor on their list. Whe I joined the medical aid they ask who your GP is and I did add the GP 's name that I have been seeing for the last 16 years on the application. As per their rules you can see a DR not contracted to their Network of Doctors 3 times per year and pay him/her and then claim the money back from Selfmed. So how I see it you can see another Dr but he can't do any tests to see what is wrong with you. Even with contracted in Dr's if they give you a script for medicine the medical aid does not pay as it is not on their list. Unfortunately I can't take a better medical plan as I am the only breadwinner and has my Partner as my dependent. I need to have a medical aid but is it worth it. Selfmed even declined a scope last year as it must be done in the rooms of the Specialist and not in a clinic. When I asked them to give me Specialists names that does it in rooms I was told they do not have anyone. They are the worst Medical Aid I ever belonged to.</p>
With reference to your complaint, please note the Scheme’s response. Each benefit option is uniquely structured and the benefits that a member is entitled to is directly related to the level of the plan and therefore the monthly contributions. The Selfnet option is a network option and is aimed at members that require emergency type hospitalisation with limited out of hospital benefits. The option does provide benefits for out of network doctors, with a limit of three consultations, subject to a R1,000.00 Medication, procedures, radiology and pathology related to the consultation is payable from this amount. Medication is paid as per Network formularies. An email was sent to you requesting additional information in order to investigate the outstanding account(s). Regards SELFMED MEDICAL SCHEME
With reference to your complaint, please note the Scheme’s response. Each benefit option is uniquely structured and the benefits that a member is entitled to is directly related to the level of the plan and therefore the monthly contributions. The Selfnet option is a network option and is aimed at members that require emergency type hospitalisation with limited out of hospital benefits. The option does provide benefits for out of network doctors, with a limit of three consultations, subject to a R1,000.00 Medication, procedures, radiology and pathology related to the consultation is payable from this amount. Medication is paid as per Network formularies. An email was sent to you requesting additional information in order to investigate the outstanding account(s). Regards SELFMED MEDICAL SCHEME