TERRIBLE CUSTOMER SERVICE FROM SIZWE

My name is Pavithra Moonsamy. I am utterly disappointed in the customer service I have recently received from both Sizwe Medical Aid as well as Enablemed with regards to assisting with a query, which to date isn't resolved nor have I received any feedback from any of the consultants I have spoken to concerning this matter.

My fiance was taken to the Life Mount Edgecombe Hospital on the 26 June 2019 to casualty in the emergency department at 4 am, he had blood tests done as well as a swab test which was done by Lancet Laboratories which amounted to R2677.80.

Firstly we were not informed at the inception of the medical aid that we need to get a pre-authorisation for any and every medical assistance required, Neither is it found stating clearly that pre-authorisation is required for any medical situation where medical attention is required on any of the documents. needless to say, this was an emergency. Secondly, we were not informed that the medical aid did not pay for the blood tests done until we received an email and multiple text messages on the 17 July 2019 stating we owe Lancet for the services provided.

I had made a call on the day that my fiance was taken to hospital(26/06/2019) to enquire about what the procedure was and the consultant told me that the medical aid would liaise directly with the hospital once the hospital submitted the claim. The claim had been rejected by medical aid stating that we did not get a pre-authorization when the consultant had informed me that they deal directly with the hospital and there isn't anything that I needed to do.

I have made numerous call to customer care to both Enablemed and Sizwe Medical Aid, to which I was first told that the claims made by the laboratory were rejected as a pre-authorisation was not made and its more than seven days and there is nothing that could be done, to which I asked what should be done as this was not our fault that we were not notified at the beginning that we need to request a pre-authorisation , the consultant blankly told me she does not know( this call was made on Friday 26/07/2019 . I was told by Enablemed customer care that they cannot assist and that I should call Sizwe because they are the administrators, I Then called Sizwe Medical aid only to be told that Enablemed should assist me with this query as they only deal with claims once the patient is admitted in hospital and that casualty is considered as out of hospital.

To date, I have not received any assistance regarding this matter and am currently sitting with a bill of R2677.80 that is not paid. I think this is absolutely ridiculous that the consultants that work in customer care are unable to assist customers with queries. Kindly assist with this matter urgently as I need to sort this out before I am handed over for something which was not my fault.