Zestlife Wrongfully Repudiated My Valid Co‑Payment Claim – Ignoring Their Own Policy Wording

Zestlife Wrongfully Repudiated My Valid Co‑Payment Claim – Ignoring Their Own Policy Wording

I am extremely disappointed with Zestlife’s handling of my recent gap cover claim (Policy GAP***) for an out‑of‑hospital CT Lumbar Spine scan performed on 19 February 2026. My medical aid (CAMAF) authorised the procedure and app**** a standard benefit co‑payment — not a penalty. I submitted this co‑payment claim to Zestlife exactly as their policy requires. Zestlife has now repudiated the claim, using the incorrect reason that my medical aid “did not pay from major medical benefit”. This is not what their policy states, and their decision directly contradicts the clear wording in the documents they issued to me. 1. Their own policy explicitly covers co‑payments for out‑of‑hospital CT scans Zestlife’s 2026 Universal Gap Cover wording states: ✔ “We will refund the co‑payment… for out‑of‑hospital Procedures listed in Appendix A.” ✔ Appendix A specifically lists “Radiology – Computer Axial Tomography (CAT) scan.” [GAP email 16 Feb | Word] This is the exact procedure I had. There are no additional requirements such as “must be paid from major medical” or “excluded if the scheme pays from savings”. 2. Zestlife app**** the wrong clause The “major medical must pay first” condition applies only to specialist tariff shortfalls, not co‑payments. My claim was not for a shortfall — it was a co‑payment. Their repudiation misapplies the policy wording. 3. CAMAF app**** a normal co‑payment — not a penalty CAMAF’s pre‑authorisation clearly states the co‑payment amount and confirms it was a standard benefit design, not a penalty and not due to any rule violation. [GAP email 16 Feb | Word] 4. Their repudiation decision is unfair and contractually incorrect I followed all scheme rules, obtained pre‑authorisation, used a contracted radiology provider, and submitted all documents. Zestlife’s refusal to pay a co‑payment that their own policy explicitly covers is unacceptable. What I expect I request that Zestlife urgently:

Reverse the incorrect repudiation; Reassess my claim using the correct Co‑payment benefit category; Process payment without delay.

I have escalated the matter to Zestlife, Guardrisk, and my broker, and will involve the National Financial Ombud if required. Customers rely on Zestlife to honour their obligations according to their own policy wording. This experience has severely damaged my trust, and I hope Zestlife resolves this swiftly and professionally.