Bestmed Medical Scheme
REFUSAL TO AUTHORISE A LEGITIMATE CLAIM

I was diagnosed with a hernia on 6 September. After consultation with a specialist and undergoing a gastroscopy, I was advised that the most effective way to treat my condition was to operate. A detailed motivation was supplied by my specialist. After a frustrating wait I was informed that my request for authorisation was denied. No clear explanation was given to me telephonically. I directed a letter to the Claims Manager requesting a detailed reason for the rejection. All I got in return was a very unprofessional computer generated pro forma letter. I will not even go into the shocking lay out and grammar on the letter, but it gave no indication in terms of which rule my claim was denied. Bestmed told me to use PPI's for 6 further months before they would reconsider. I am advised that the PPI's opens me to a risk of osteoporosis. The PPi's have up to date had no effect and I live with a constant pain.

I feel like a criminal having to submit report after report and thereafter I have to beg for cover. I am of the opinion that their rejection is unlawful, thus I need a detailed letter setting out the reasons. I INTEND REFERRING THIS LETTER TO THE CMS.

I await your urgent response

Company: Bestmed Medical Scheme
Country: South Africa
City: Claims/Authorisations

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