Will not pay out gap cover claim

Refusing to pay out my claim.

My daughter had her tonsils and adenoids removed on 25.11.2019. The ICD10 code for this is J35.3.

According to Stratum this code is a PMB and they will not pay for it. Upon requesting why they see tonsillectomy as a pmb it was said that the above code is for the following procedure: central perforation of tympanic membrane.

This is untrue as I verified with my medical aid and with my Dr. This code is for hypertrophy of tonsils with hypertrophy of adenoids.

Still they insist they are correct and I am wrong.

They are arrogant with no customer service. They try any trick in the book not to pay your claim out.