MW
Miets W
1 reviews | Active since Jan 2020
06 Feb 2020, 12:19
TRA not paying all costs medical aid is not paying when being hospitalized, even if you're covered up to 700%
TRA Gap cover refusing to pay procedure "in-hospital" the medical aid is not paying, i.e. after being hospitalized, be careful, they do not pay all the bills the medical aid's not covering when you're in hospital, that after they pride themselves in paying up to 700%!!
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Replies (6)0
Replies (6)
Total Risk Administrators's replyOfficial
06 Feb 2020, 16:22Dear Ms Wagstaff
We do apologise for the inconvenience. I will investigate the problem and revert back to you by tomorrow morning.
TRA Management
We do apologise for the inconvenience. I will investigate the problem and revert back to you by tomorrow morning.
TRA Management
Total Risk Administrators's reply06 Feb 2020, 16:22
Official
Dear Ms Wagstaff
We do apologise for the inconvenience. I will investigate the problem and revert back to you by tomorrow morning.
TRA Management
We do apologise for the inconvenience. I will investigate the problem and revert back to you by tomorrow morning.
TRA Management
Total Risk Administrators's replyOfficial
07 Feb 2020, 13:36Dear Ms Wagstaff
I have investigated your claim and have listened to the conversation between your husband and one of our consultants.
If your medical aid declines a procedure, we as a Gap Cover cannot pay for the procedure. We are not allowed to take on the role of a medical aid. We fall under insurance and only covers the difference between what the Doctor charges and your medical aid paid (more than medical aid rates).
Can I suggest that you contact your medical aid as they should provide you with a valid reason for declining your procedure.
TRA Management
I have investigated your claim and have listened to the conversation between your husband and one of our consultants.
If your medical aid declines a procedure, we as a Gap Cover cannot pay for the procedure. We are not allowed to take on the role of a medical aid. We fall under insurance and only covers the difference between what the Doctor charges and your medical aid paid (more than medical aid rates).
Can I suggest that you contact your medical aid as they should provide you with a valid reason for declining your procedure.
TRA Management
Total Risk Administrators's reply07 Feb 2020, 13:36
Official
Dear Ms Wagstaff
I have investigated your claim and have listened to the conversation between your husband and one of our consultants.
If your medical aid declines a procedure, we as a Gap Cover cannot pay for the procedure. We are not allowed to take on the role of a medical aid. We fall under insurance and only covers the difference between what the Doctor charges and your medical aid paid (more than medical aid rates).
Can I suggest that you contact your medical aid as they should provide you with a valid reason for declining your procedure.
TRA Management
I have investigated your claim and have listened to the conversation between your husband and one of our consultants.
If your medical aid declines a procedure, we as a Gap Cover cannot pay for the procedure. We are not allowed to take on the role of a medical aid. We fall under insurance and only covers the difference between what the Doctor charges and your medical aid paid (more than medical aid rates).
Can I suggest that you contact your medical aid as they should provide you with a valid reason for declining your procedure.
TRA Management
MW
Miets W's updateReviewer Update
25 Mar 2020, 18:36Our procedure was appealed and resubmitted to the medical aid, upon which it was then approved, and a portion of the procedure was subsequently paid by the medical aid.
TRA Gap cover still refuses to pay for the remaining balance of the procedure not paid by the medical aid, that after proof of authorisation of the procedure, and part payment was provided to TRA.
TRA Gap cover still refuses to pay for the remaining balance of the procedure not paid by the medical aid, that after proof of authorisation of the procedure, and part payment was provided to TRA.
MW
Miets W's update25 Mar 2020, 18:36
Reviewer Update
Our procedure was appealed and resubmitted to the medical aid, upon which it was then approved, and a portion of the procedure was subsequently paid by the medical aid.
TRA Gap cover still refuses to pay for the remaining balance of the procedure not paid by the medical aid, that after proof of authorisation of the procedure, and part payment was provided to TRA.
TRA Gap cover still refuses to pay for the remaining balance of the procedure not paid by the medical aid, that after proof of authorisation of the procedure, and part payment was provided to TRA.
Total Risk Administrators's replyOfficial
25 Mar 2020, 19:22Dear Mrs Wagstaff
Medication/materials used on a radiology account is not covered by TRA.
Your medical aid has only authorized a portion of the claim and rejected the balance of the account as authorisation denied. If any portion of an account is declined by your medical aid, gap cover will not cover the claim as the medical aid paid nothing towards the claimed amount. As a Gap Cover we are not allowed to take over the role of your medical aid.
May I suggest once more that you ask your medical aid why half of the authorisation was declined?
TRA Management
Medication/materials used on a radiology account is not covered by TRA.
Your medical aid has only authorized a portion of the claim and rejected the balance of the account as authorisation denied. If any portion of an account is declined by your medical aid, gap cover will not cover the claim as the medical aid paid nothing towards the claimed amount. As a Gap Cover we are not allowed to take over the role of your medical aid.
May I suggest once more that you ask your medical aid why half of the authorisation was declined?
TRA Management
Total Risk Administrators's reply25 Mar 2020, 19:22
Official
Dear Mrs Wagstaff
Medication/materials used on a radiology account is not covered by TRA.
Your medical aid has only authorized a portion of the claim and rejected the balance of the account as authorisation denied. If any portion of an account is declined by your medical aid, gap cover will not cover the claim as the medical aid paid nothing towards the claimed amount. As a Gap Cover we are not allowed to take over the role of your medical aid.
May I suggest once more that you ask your medical aid why half of the authorisation was declined?
TRA Management
Medication/materials used on a radiology account is not covered by TRA.
Your medical aid has only authorized a portion of the claim and rejected the balance of the account as authorisation denied. If any portion of an account is declined by your medical aid, gap cover will not cover the claim as the medical aid paid nothing towards the claimed amount. As a Gap Cover we are not allowed to take over the role of your medical aid.
May I suggest once more that you ask your medical aid why half of the authorisation was declined?
TRA Management
MW
Miets W's updateReviewer Update
25 Mar 2020, 20:59It was not declined, clearly you're only responding with generic responses and not properly looking into the case. Proof has been provided that the case was subsequently approved, not declined, following TRA management's advice to get the procedure approved, "as long as the medical aid pay a portion, TRA will pay the balance", empty promises to the consumer.
Just a reminder that it was ONE PROCEDURE, done in hospital, while being in hospital for 5 days, of which the medical aid paid a portion, exactly as per the policy documents TRA is covering! Just to find out that TRA is looking for all ways out of paying claims, dissecting each part of one hospital procedure! This is exactly the frustration people need to know about before considering TRA. Please get someone in management to email on what legal basis this is being denied per the policy signed so that this could be forwarded to the onbuds man.
Just a reminder that it was ONE PROCEDURE, done in hospital, while being in hospital for 5 days, of which the medical aid paid a portion, exactly as per the policy documents TRA is covering! Just to find out that TRA is looking for all ways out of paying claims, dissecting each part of one hospital procedure! This is exactly the frustration people need to know about before considering TRA. Please get someone in management to email on what legal basis this is being denied per the policy signed so that this could be forwarded to the onbuds man.
MW
Miets W's update25 Mar 2020, 20:59
Reviewer Update
It was not declined, clearly you're only responding with generic responses and not properly looking into the case. Proof has been provided that the case was subsequently approved, not declined, following TRA management's advice to get the procedure approved, "as long as the medical aid pay a portion, TRA will pay the balance", empty promises to the consumer.
Just a reminder that it was ONE PROCEDURE, done in hospital, while being in hospital for 5 days, of which the medical aid paid a portion, exactly as per the policy documents TRA is covering! Just to find out that TRA is looking for all ways out of paying claims, dissecting each part of one hospital procedure! This is exactly the frustration people need to know about before considering TRA. Please get someone in management to email on what legal basis this is being denied per the policy signed so that this could be forwarded to the onbuds man.
Just a reminder that it was ONE PROCEDURE, done in hospital, while being in hospital for 5 days, of which the medical aid paid a portion, exactly as per the policy documents TRA is covering! Just to find out that TRA is looking for all ways out of paying claims, dissecting each part of one hospital procedure! This is exactly the frustration people need to know about before considering TRA. Please get someone in management to email on what legal basis this is being denied per the policy signed so that this could be forwarded to the onbuds man.
Total Risk Administrators's replyOfficial
26 Mar 2020, 06:55Dear Mrs Wagstaff
Please provide me with the details of the Doctor that you are referring to. According to the information that I found on our system, there was a Radiology account that was not paid and authorised in full by the medical aid. As soon as I receive your response, I will look into the matter again.
Please accept my sincerest apology for the misunderstanding.
TRA Management
Please provide me with the details of the Doctor that you are referring to. According to the information that I found on our system, there was a Radiology account that was not paid and authorised in full by the medical aid. As soon as I receive your response, I will look into the matter again.
Please accept my sincerest apology for the misunderstanding.
TRA Management
Total Risk Administrators's reply26 Mar 2020, 06:55
Official
Dear Mrs Wagstaff
Please provide me with the details of the Doctor that you are referring to. According to the information that I found on our system, there was a Radiology account that was not paid and authorised in full by the medical aid. As soon as I receive your response, I will look into the matter again.
Please accept my sincerest apology for the misunderstanding.
TRA Management
Please provide me with the details of the Doctor that you are referring to. According to the information that I found on our system, there was a Radiology account that was not paid and authorised in full by the medical aid. As soon as I receive your response, I will look into the matter again.
Please accept my sincerest apology for the misunderstanding.
TRA Management