FP
Francis P

1 reviews | Active since Jan 2020

11 Jun 2021, 11:42

Appliance not Paid

Member Name: Florrie Jordaan Member N0: *** ID no: *** My mom is on the Titanium Executive Plan. Her Appliance Benefit per year is R2936. On the 22nd of April I phoned the fund to find out what I must do to get authorization to purchase a walker for my mom, as she had fallen an broken her knee and the breaks on her walker was not working. The call center consultant I spoke to said there is no authorization required, as long as we stay within the limit. She did not mention that I have to purchase from a certain supplier. I purchased a Walker wheelchair in one from Dischem Glen Acres Pharmacy on the 23/03/2021 for an amount of R3041.44. My mom could not manage with this wheelchair/walker so returned it on the 24/03/2021. Dischem did not have a walker with a seat attached to it in stock. My brother made an online purchase from Clinihealth which was the cheapest online for an amount of R1850. Clinihealth is a wholesaler. So they do not have a practice number. Now Sizwe will not refund us. Please can you answer me on the following: 1) Nowhere in your Benefits list does it say that only certain suppliers are to be used. 2) I did phone for Authorization and this was not mentioned to me. 3) If we saved you money by purchasing from a cheaper supplier, why won't you refund us? 4) Where does it state that only certain suppliers can be used to purchase appliances. This should be available for the public to see!!

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Replies (2)
Sizwe Hosmed Medical Scheme
Sizwe Hosmed Medical Scheme's reply11 Jun 2021, 12:04
Official
Dear Francis,

We acknowledge receipt of your comments. One of our consultants will contact you shortly to assist with your query.

With Care
Team Sizwe
Sizwe Hosmed Medical Scheme
Sizwe Hosmed Medical Scheme's reply23 Jun 2021, 14:36
Official
Dear Francis,

We have received feedback from the Escalations Team

Unfortunately, the reason for the rejection of your claim is part of the Council for Medical Schemes rules and Sizwe Medical Rules https://www.medicalschemes.co.za/ and http://www.sizwe.co.za/rules-and-amendments/

Which state that before any medical scheme will pay a medical practitioner, he/she and the practice has to be registered with the Health Professions Council of South Africa. 

It is not a Sizwe rule, all other medical aids must comply with that rule

We apologize for the inconvenience caused by this

Regards
Operations Manager