SizweHosmed Escalation Process Non-Existent

I have been with the fund for 20 years and 2023 has been the worst year to deal with them. My premiums are always paid on time but claims payments delayed up to 3 months.

Its the 23/01/24 and I am still waiting for a provider to be paid relating to a emergency hospitalization on the 21/10/2023. The claims department had incorrectly captured the claim with no modifiers. I have called the call center 7 times to escalate with a response received that there is a backlog of claims and it is in the que for reprocessing. I have requested to talk to a team leader and even asked them to call me back as no agent could confirm when the account would be settled in all 7 instanced. To date, no one has contacted me.

Further to this, I have followed the chain of escalation to the complaints department, CRDC, CMS, and principal officer and allowed sufficient time for each of them to respond. No response received from anyone.

I will be submitting the case to the council of medical schemes as the advertised escalation process on their website does not work - no feedback within advertised time frames. An escalation process is a fundamental requirement for any medical scheme to operate.