Resolution Health Medical Scheme
Double standards

My son was born last year with Bilateral Cleft lip and palate. This immediately falls under a Prescribed Minimum Benefit according to Medical Schemes Act. He had his first op last year December. We confirmed specifically with Resolution Health that it is a PMB procedure and are unable to have the procedure done at any other hospital, besides Life Wilgers with Prof K Butow. We had no problem with Resolution Health and they paid the full accounts. My son is on the Progressive Flex option, which he was covered on from birth.
The problem is with the second operation, which was June 2013. First we found out late about the change the scheme rules that they no longer cover Life hospitals, so we were told we need to pay a co-payment of R3000 where last year there was no co-payment. After a number of phone calls we managed to help them understand that it was not a procedure that we could've done at another hospital or with another surgeon. finally waived co-payment. We had all authorisation in place under PMB. Now after submitting the account of 2nd op, they only pay a small portion. Why the reluctance to pay everything, it is still a PMB with the same surgeon?? Mrs de Wet

Company: Resolution Health Medical Scheme
Country: South Africa
City: Pretoria

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