Material misrepresentation, Maladministration, and a Failure to exercise due care when confirming medical aid benefits

Formal Complaint and Request for Investigation – Boardwalk / Port Elizabeth Branch - EXECUSPECS

This complaint was sent to *** on the 20 January 2026, no feedback received to date. Dear Sir / Madam,

I am writing to formally lodge a complaint and to request a comprehensive investigation into the conduct and administrative practices of the Boardwalk / Port Elizabeth Branch , specifically relating to the handling of my medical aid verification, quotations, claims submission, and subsequent communication.

This complaint arises from a series of events that indicate material misrepresentation, maladministration, and a failure to exercise due care when confirming medical aid benefits—resulting in financial prejudice to me as the customer.

Background and Chronology On Saturday, 20 December 2025, I provided Ms Phumeza [Surname unknown] with my identity document and medical aid details in advance of a scheduled consultation. The purpose was explicitly to allow the branch sufficient time to confirm my medical aid benefits and limitations so that, when I attended my appointment, there would be full clarity on what services and products were covered.

I had a confirmed appointment at your Boardwalk / Port Elizabeth Branch on Monday, 22 December 2025 at 10:00. On the morning of the appointment, Ms Phumeza contacted me to confirm attendance but advised that the branch had not been able to verify my medical aid benefits and limitations. I was informed that if I still wished to proceed, I would need to pay the consultation fee out of pocket. I advised her to cancel the appointment until such confirmation could be obtained.

Approximately ten minutes later, Ms Phumeza contacted me again, advising that contact had now been made with the medical aid and that my benefits and limitations had been confirmed. Based on this assurance, the appointment was rescheduled for 10:30.

I proceeded with the consultation and was advised that a promotion was running on a second frame. Following the consultation, Ms Pumeza engaged with me regarding the confirmed medical aid amounts. I explicitly asked which frame ranges were within my confirmed medical aid funding. I was categorically advised that there were more than sufficient funds for both a first and second frame, and that I could select from any branded frames without concern.

Relying on this assurance, I selected two frames. Quotations were prepared based on the alleged confirmed benefits, and I signed accordingly. I was advised that delivery would be delayed due to the festive period, with expected completion in mid-January.

The amounts were as follows:

First pair of spectacles: R7,545.00

Second pair (sunglasses): R3,564.00

Claim Irregularities and Failure to Act Around 30 December, my wife received notification from the medical aid indicating that:

The claim for the sunglasses had been rejected, and

The claim for the primary spectacles had only been partially approved.

Between 30 December and 2 January, my wife contacted the branch repeatedly and spoke to Ms Phumeza , advising her of the partial approval and rejection and requesting that this be investigated and clarified. These requests were ignored.

We contacted the branch again on 2 January, having also spoken directly with the medical aid, who confirmed that sufficient funds were available from 1 January for the previously unpaid items and that resubmission was possible. Despite this, no resubmission was done, and no explanation was provided.

Throughout this period, we were repeatedly told that only the sunglasses were rejected and that the first pair was fully paid—information which later proved to be incorrect.

On 9 January, I requested confirmation of the outstanding balance and was provided only with an invoice for the second pair, in the amount of R2,929.00, reinforcing the incorrect narrative that the first pair was fully settled.

Discovery of Improper Benefit Verification On Saturday, 17 January 2026, I visited the branch in person due to the absence of any communication regarding collection. During my engagement with Ms Phumeza , it became evident that the benefits confirmation process she re**** upon on 22 December was fundamentally flawed.

Under direct questioning, she conceded that:

She did not speak to a medical aid consultant to confirm my benefits;

She re**** solely on a system prompt/machine response; and

She had no reference number or verifiable proof of benefits confirmation.

I explained that such prompts only reflect high-level benefit categories and do not confirm individual member limitations, available basket balances, or remaining funds. Without consultation with the medical aid, it would have been impossible for her to accurately advise me on eligibility or affordability.

The absence of any reference number further confirms that no proper benefits verification took place.

Basis of Complaint In my view, the actions of Ms Phumeza constitute:

Material misrepresentation of confirmed medical aid benefits;

Negligent administration of medical aid verification and claims;

Failure to act when alerted to partial approvals and rejections;

Provision of misleading and contradictory information over an extended period; and

Conduct that resulted in financial prejudice to me as the customer.

I selected frames and entered into contractual commitments solely on the basis of assurances that benefits had been properly verified. This later proved to be false. This matter cannot be dismissed as an isolated error. It raises serious concerns regarding how many other customers may have been similarly misled into selecting products based on unverified or improperly confirmed medical aid benefits.

Given the seriousness of these issues, one could reasonably argue that the conduct borders on *****ulent misrepresentation.

Request I formally request:

A full investigation into the conduct and practices of the Boardwalk / Port Elizabeth Branch ;

A review of Ms Phumeza medical aid verification procedures;

A written explanation addressing the inconsistencies, failures and misrepresentations outlined above; and

Appropriate remedial action to resolve the financial prejudice suffered.

I am forwarding my previous correspondence as an attachment for context and evidence.

I expect a formal response from Head Office within a reasonable timeframe.

Yours faithfully, Ralton Grootboom

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