GEMS callcenter saying they do not have managers on site

deedee

Member
Joined
Aug 3, 2010
Messages
10
Hi there,

I am hoping someone can give me advise on handling a claims situation. My parents are both unemployed, my dad was medically boarded and is on dialysis. Recently with my dads healthy deteriorating at a rapid pace my brother who lives in Thailand and I live in Seattle decided to take my parents on a family trip to Thailand. While abroad my dad was receiving dialysis at an international hospital in Phuket that charged a standard fee of 7000 baht. Prior to leaving the Gems call-centre informed my parents that they will be reimbursed approximately R1800 of the fee paid per session whilst abroad. They paid the fee in cash and received printed receipts detailing the treatment received and had a big red stamp saying "PAID" on the invoices. They have spent a total of R21 k on these treatments and was only expecting R12 k back from GEMS. Anyway GEMS claims is now refusing to accept these receipts, saying anyone can produce printed copies, and each time my parents are contacting the call-centre the agents are refusing to let them speak to a superior or they are hanging up on them. My brother in the interim was trying to obtain alternative receipts but the hospital can't modify it and all the information such as the Dr. practice number and hospital info is on the receipts. They are giving some bogus excuse questioning why the invoice totals are exactly the same? Dur it's because it was a standard procedure with a standard charge. Does anyone have experience in dealing with Claims at Gems medical aid or an escalation path that can be followed. Writing off R12k is too much for folk who are unemployed. Any advice or assistance will be appreciated.
 

ambroseg1

Honorary Master
Joined
Jul 15, 2008
Messages
11,027
unfortunately no advice. Im also gems and know them to be monumentally crap. ONLY reason why we stick with them is massive costs savings. They have truly become a stereotypical government entity.
 

akescpt

Honorary Master
Joined
Aug 12, 2008
Messages
21,255
Why didn’t you and your brother cover the treatment instead of your unemployed parents?

Take the proof of the undertaking to pay the R1.8k by them with the receipts and sit down with someone at a walk in center. There must be a supervisor on duty there surely.
 

now05ster

Senior Member
Joined
Dec 8, 2011
Messages
869
Ask if there is a formal disputes process to follow before you got to the council of medical schemes. If there is no such process then got to the council of medical schemes.

You will wait a while though, hope you rather get to speak to someone knowledgeable though.

Have you tried social media?
 

Grant

Honorary Master
Joined
Mar 27, 2007
Messages
47,242
If GEMS are trying to claim the invoices could be bogus, call the claims dept and ask for the manager and explain the situation & follow up that conversation with an email them, confirming the conversation. In the email tell them, given they will not accept the invoices you have provided, they must now obtain whatever it is they require directly from the case manager at the hospital & nephrologist who treated your father.

In that letter, mention you had previously tried to have this claim finalized with them & should they fail to settle the claim you will have no alternative but to refer the matter to the Council of Medical Schemes of South Africa.

CMS interestingly is one of the few bodies that have real teeth. All medical schemes, by law, have to comply with their rules. They fight, and they fight hard, regularly taking matters as far as the Appeals Court on behalf of medical scheme members.

There is some interesting info here:

I have had dealings with them and have found them to be remarkably efficient.
In my case, my mother has been in and out of hospital for the last 3 yrs, had multiple surgeries etc, the total costs hit the R5m mark in December.
On a few occasions there were disputes which I referred to CMS, all of them handled quickly and efficiently.

GEMS is administered by Metropolitan Health Group
770434

**anyone else reading this thread, take a look at the 2nd link above & look for matters involving your own medical scheme
 

deedee

Member
Joined
Aug 3, 2010
Messages
10
Why didn’t you and your brother cover the treatment instead of your unemployed parents?

Take the proof of the undertaking to pay the R1.8k by them with the receipts and sit down with someone at a walk in center. There must be a supervisor on duty there surely.
 

deedee

Member
Joined
Aug 3, 2010
Messages
10
We did pay for half of it and also covered their flights, accommodation and expenses while abroad. My parents didn't want to be a burden so they contributed what they can. Still think its unfair that GEMS is giving them the run around.
 

akescpt

Honorary Master
Joined
Aug 12, 2008
Messages
21,255
We did pay for half of it and also covered their flights, accommodation and expenses while abroad. My parents didn't want to be a burden so they contributed what they can. Still think its unfair that GEMS is giving them the run around.
I’m not happy about the GEMS behavior. That needs to be sorted and decisive action taken ASAP.

I assumed you paid for things since you took them over. Just couldn’t understand them paying for medical things.
 

RvdWesthuizen

New Member
Joined
Jan 20, 2020
Messages
1
Dear Deedee, I have noted your comment and wish to be off assistance. Kindly can you reach out to me with the membership number in order for the matter to be looked at. Regards Mrs van der Westhuizen, GEMS

Hi there,

I am hoping someone can give me advise on handling a claims situation. My parents are both unemployed, my dad was medically boarded and is on dialysis. Recently with my dads healthy deteriorating at a rapid pace my brother who lives in Thailand and I live in Seattle decided to take my parents on a family trip to Thailand. While abroad my dad was receiving dialysis at an international hospital in Phuket that charged a standard fee of 7000 baht. Prior to leaving the Gems call-centre informed my parents that they will be reimbursed approximately R1800 of the fee paid per session whilst abroad. They paid the fee in cash and received printed receipts detailing the treatment received and had a big red stamp saying "PAID" on the invoices. They have spent a total of R21 k on these treatments and was only expecting R12 k back from GEMS. Anyway GEMS claims is now refusing to accept these receipts, saying anyone can produce printed copies, and each time my parents are contacting the call-centre the agents are refusing to let them speak to a superior or they are hanging up on them. My brother in the interim was trying to obtain alternative receipts but the hospital can't modify it and all the information such as the Dr. practice number and hospital info is on the receipts. They are giving some bogus excuse questioning why the invoice totals are exactly the same? Dur it's because it was a standard procedure with a standard charge. Does anyone have experience in dealing with Claims at Gems medical aid or an escalation path that can be followed. Writing off R12k is too much for folk who are unemployed. Any advice or assistance will be appreciated.
 
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