Successful ruling via CMS?

dunkyd

dunkyd

Executive Member
Joined
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Anybody had a ruling against a medical aid ?
Waiting 6 months now and getting nowhere !!
Starting to wonder if they have also been "captured"
 
Nope. never successful...
They have indeed also been captured.. in this case by Adrian Gore and his chums.
 
ArtyLoop said:
Nope. never successful...
They have indeed also been captured.. in this case by Adrian Gore and his chums.
Click to expand...
The very same guy I'm fighting with... PMB stroke rehab suddenly stopped without rhyme or reason.
 
Said a-hole wouldn't pay for a PMB... we tried and tried.. eventually CMS said no, so we told Discovery to go fark themselves too.. And I just smile when they have the audacity to send me their SMS messages that I owe them money...
 
I made a complaint against Prime Care - the Netcare medaid in previous years.

Their administration was so ballsed-up that it was unbelievable, especially for a medical company.

No action was taken against Prime Care, although shortly after that we did dump them and are now administered by Discovery.
 
From my experience, CMS decisions are mostly against the client - largely because of members not fully understanding the benefits of the scheme. (Not saying this is happening here, but just my experience).

In general, my advice to anyone who has an issue with their Medical Aid is to follow the internal dispute mechanism right up to the principal officer before engaging with the CMS. When it is a declined benefit issue relating to PMBs, medical aids have a very difficult time disputing the motivation of the practitioner who is treating your condition when their motivation is detailed and based on empirical evidence.
 
3 therapists submitted detailed reports outlining the benefits of more sessions to no avail.
Now CMS want more reports but sadly the therapists have not been paid and are not willing to waste more effort to help us.
 
I think PMB benefits especially relating to an acute incident do have a time period eg 3 months etc etc

This will be in the scheme rules - but good luck getting those!
 
I have won two cases against my Medical Aid with the CMS. You have to make the case yourself, supply all supporting documents etc. I sent everything that I had already sent to Medical Aid to the CMS. They e-mailed the Scheme, attached the docs with an e-mail requesting a response. The response was that the Medical Aid would settle the claims. Both my cases were very clear cut breaches of the Medical Schemes Act.
 
Thanks.
I actually WON my case via the CMS.
Got ruling on 6th August that Discovery must carry on paying for rehab thereapy for my paralyzed wife, being PMB.
Discovery then phoned twice and emailed twice to tell me that they have 3 months to decide if they feel like appealing !!!!
1 month to go.
Should they appeal I will plan the biggest media bashing I can.......
 
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