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Andre S

1 reviews | Active since Jan 2013

15 Mar 2022, 15:39

No proper service for unnecessary red tape

I would like to keep this short, so here I go. The company insists on having a statement from my medical aid for a claim that I have on a co payment. Now I know all about policies, as I am an Internal Auditor but I can also see when red tape is just overdone, which makes it difficult and drags out the timeframe within which a claim is settled.

Why doe I need a statement from my medical aid, if I have an authorization letter from them that states that I have to pay a co payment before a procedure can be done, for which I also have a receipt from the hospital that was paid, as well as a point of sales slip that is from another party(three parties confirming that I had to pay, and paid the co payment) as well as an invoice from the hospital that shows the same amount that was paid.

I know all about audit trails and the documents that I already sent to you should be more than sufficient to show that the amount was paid and was for this procedure, as you can simply log onto my medical aid and see for yourself that the co payment that I am claiming is a pre requisite for my operation, so why on God's green earth do you need me to claim the co payment from my medical aid, just to be refused the claim as they insisted that I pay this co payment in the beginning, just so that you can see that they have declined something that they will never pay??

I think this is clearly to frustrate customers so that some of hem give up and you don't have to pay, as three separate confirmations that something was paid should be more than sufficient to show that this refund is due to me. Now I have to sit out of pocket until the end of the month when my medical aid will give me a statement, and then have to wait another 10 days as per your own set deadlines. Don't blame this on any laws, as the paperwork needed is your own requirements, and to make someone have to beg for a refund that is not feeling well after their operation, I think is in bad taste.

Excuse my grammar as I am writing this while not feeling well, but I hope others see this and think before going with Stratum, who makes a claim a very stressful process, for no apparent reason.

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Replies (2)
Stratum Benefits (Pty) Ltd
Stratum Benefits (Pty) Ltd's reply18 Mar 2022, 07:57
Official
Good morning Andre
 
We hear your frustrations and we’re sorry that our claims process seems to be the cause of it, but allow us to explain. 
 
The pre-authorisation letter speaks to an upcoming medical event for which a co-payment is payable. This in itself is not confirmation that you’ve undergone the procedure and paid a co-payment.
 
The reason we require a medical aid statement is because this document shows us how your medical aid processed all the healthcare and service providers’ accounts related to the medical event, and that a co-payment was indeed app****. The medical event you’re claiming for has been identified as a possible Prescribed Minimum Benefit (PMB) medical procedure which your medical aid should cover in full. It’s therefore important for our assessing purposes to first see how your medical aid treats the event and how they cover it so that we can accurately assess any shortfalls and determine whether the co-payment is refundable by your Gap Cover policy. 
 
The proof of payment showing that the co-payment amount was paid by you forms part of the claims documents we require, but we still need to first determine how your medical aid app**** it to your medical event which the final medical aid statement will show.
 
Please send us the medical aid statement as soon as you receive it so that we can finalise your claim.
 
Best regards,
The Stratum Benefits Team
AS
Andre S's update18 Mar 2022, 09:08
Reviewer Update
So the fact that I paid for the copayment and the attached these supporting documents (pos slip and hospital receipt) along with a statement from the service provider(hospital) that shows what they charged, as well as a subsequent mail with a screen shot from my medical aid website that shows what they paid to the hospital, and an excel spreadsheet from me that show what was claimed by hospital and what they actually paid to the hospital which comes to a variance of the exact same amount as the co payment that I paid was still not good enough, this smacks of red tape to ensure the most difficult process to actually pay someone in the hope that they would give up.