Poor Transparency and Unclear Claim Rejections

My experience with Bestmed has been extremely disappointing. Communication regarding rejected claims is unclear and often evasive. When I asked for a detailed explanation of why certain claims were declined, I did not receive a direct answer explaining the reasoning or the criteria used to make the decision.

Instead, responses typically avoid addressing the specific question and provide general statements without clarifying the underlying logic behind the claim decision. I escalated the matter to senior staff, including the Head of Department and the complaints department. While I eventually received an apologetic response, the core issue—why the claim was rejected and what evidence or rules were used to make that determination—remains unanswered.

Only after I indicated that I might approach the Council for Medical Schemes (CMS) for assistance did I receive further correspondence. However, even then, the response did not provide the technical reasoning behind the claim rejection.

As a member, all I am asking for is transparency:

What evidence was used to evaluate the claim?

Which specific scheme rules were app****?

Why does the scheme consider part of the claim outside the benefits?

Without clear answers to these questions, the process feels opaque and unnecessarily difficult for members trying to understand their benefits.

Below is part of the response I received from Bestmed:

"We confirm that your complaint was discussed by the Medical Advisors during the weekly Clinical Advisory Committee meeting. After careful consideration of the matter in line with the scheme rules and funding guidelines, it was suggested that you contact the Council for Medical Schemes (CMS) for independent verification and guidance."

In my view, members should not need to approach the regulator simply to obtain a clear explanation of their benefits.

Based on my experience, I would recommend that potential members carefully compare alternatives before choosing Bestmed. I am personally considering moving to another scheme such as Bonitas, due to the ongoing difficulties I have experienced in obtaining clear and transparent claim explanations.