My partner was admitted to Olivedale Hospital with sub-acute bacterial endocarditis (a PMB).
He needed an aorta valve replacement as well as a pacemaker (also a PMB).
Because of the seriousness of the infection, he had to have daily IV antibiotics for 6 weeks after the operation, as part of the "medical management" of the condition. We only have a hospital plan, and Genesis refused the injections to be done in hospital. We therefore paid R1, 500 a day for 6 weeks.
Genesis left part of the valve replacement, the pacemaker and surgeon unpaid, as well as the continuous medical management.
Their reason for refusal to pay was that we had these conditions treated in a private hospital, not a state/public hospital.
- One of their proud selling points is that they don't have designated service providers (DSP) because their members are FREE TO CHOOSE. Great.
- Their Main Rules state that 100% of PMBs will be paid for if treated in a state/public hospital or at a DSP.
Why use wording "DSP" if it means nothing? If we are Free to Choose, why can we not substitute "DSP" with "own provider"? From being an advantage, Free to Choose now becomes a liability.
We have lodged complaint with CMS.
0 comments