Genesis Medical Scheme
1.8|172 reviews
MP
Merle P
1 reviews | Active since Member
15 Jan 2026, 09:50
NON PAYMENT OF EMERGENCY CODES FOR EMERGENCY OPERATION TO HAND
I had a near fatal fall and fractured/broke my left distal radius, it was severely displaced, the bone was pushed into place at orthopedic trauma hospital and cast fitted. It was an emergency that required immediate surgery but because of the severity of the fracture the swelling made it impossible for surgery immediately which was only performed 2 days later but it was still an emergency as failure to operate would result in total loss or function of hand, Genesis refuse to pay the emergency codes on ALL the bills including orthopedic trauma doctor, aneathatist, theatre etc etc despite the doctor sending a motivational letter to Genesis ...they still refuse to pay.
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Replies (56)Genesis Medical Scheme's replyOfficial
15 Jan 2026, 13:46 Dear Mrs Piner First of all, we would like to express our empathy for the unexpected, untimely and unfortunate accident you had in December. An accident like this can be truly traumatic and wish you a speedy and complete recovery. We’ve had a look at your claims and would like to provide the following feedback. All claims in respect of the Orthopaedic Surgeon, the Anaesthetist and Occupational Therapist, as well as the hospital and related accounts, including all Radiology claims, have been funded in full according to the benefits available on your selected benefit option, i.e. at 200% of the Scheme Tariff.
There is however a portion of some of the accounts that were not paid in full. These charges relate to either the service providers charging more than the Scheme Tariff (200%), or where the providers billed emergency modifiers that were not relevant in the treatment that you received.
In order for a medical scheme to pay for emergency modifiers, the treatment must meet the legal as opposed to the clinical criteria of an “emergency medical condition” as defined in the Medical Schemes Act:
“….. the sudden and, at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.”
The condition must therefore require “immediate” life-saving treatment and not “urgent” treatment, as was the case with your accident, where the operation took place three days after your accident.
Furthermore, your admission to a private hospital was voluntary, meaning that all claims were not subject to reimbursement as a PMB, but to the extent of the limits applicable to your selected benefit option. This was clearly communicated to you and your service providers prior to your operation.
Genesis has reimbursed all claims in line with your benefit option. We therefore encourage you to contact the doctors and request them to amend / correct their invoices. It may be that you and or your doctors are unaware that all medical schemes are bound to apply the law and the terms of the contract entered into voluntarily by members. The benefit option voluntarily selected by you contains no benefits for emergencies that do not comply with the legal definition.
As much as we would have liked for all your claims to be settled in full, this was unfortunately not possible due to the limits on the benefit option selected by you, but as stated above, your remedy lies with your doctors and not Genesis. Although your treatment (operation) may have been clinically urgent, it does not satisfy the criteria to qualify as a bona fide emergency, in the legal sense as set out in Regulation 7 of the Medical Schemes Act that is binding on you and the Scheme. We trust that our explanation will assist you in understanding why a portion of some of your claims was not paid in full.
Yours sincerely
GENESIS MEDICAL SCHEME
There is however a portion of some of the accounts that were not paid in full. These charges relate to either the service providers charging more than the Scheme Tariff (200%), or where the providers billed emergency modifiers that were not relevant in the treatment that you received.
In order for a medical scheme to pay for emergency modifiers, the treatment must meet the legal as opposed to the clinical criteria of an “emergency medical condition” as defined in the Medical Schemes Act:
“….. the sudden and, at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.”
The condition must therefore require “immediate” life-saving treatment and not “urgent” treatment, as was the case with your accident, where the operation took place three days after your accident.
Furthermore, your admission to a private hospital was voluntary, meaning that all claims were not subject to reimbursement as a PMB, but to the extent of the limits applicable to your selected benefit option. This was clearly communicated to you and your service providers prior to your operation.
Genesis has reimbursed all claims in line with your benefit option. We therefore encourage you to contact the doctors and request them to amend / correct their invoices. It may be that you and or your doctors are unaware that all medical schemes are bound to apply the law and the terms of the contract entered into voluntarily by members. The benefit option voluntarily selected by you contains no benefits for emergencies that do not comply with the legal definition.
As much as we would have liked for all your claims to be settled in full, this was unfortunately not possible due to the limits on the benefit option selected by you, but as stated above, your remedy lies with your doctors and not Genesis. Although your treatment (operation) may have been clinically urgent, it does not satisfy the criteria to qualify as a bona fide emergency, in the legal sense as set out in Regulation 7 of the Medical Schemes Act that is binding on you and the Scheme. We trust that our explanation will assist you in understanding why a portion of some of your claims was not paid in full.
Yours sincerely
GENESIS MEDICAL SCHEME
Best regards,
Genesis Medical Scheme's reply15 Jan 2026, 13:46
Official
Dear Mrs Piner First of all, we would like to express our empathy for the unexpected, untimely and unfortunate accident you had in December. An accident like this can be truly traumatic and wish you a speedy and complete recovery. We’ve had a look at your claims and would like to provide the following feedback. All claims in respect of the Orthopaedic Surgeon, the Anaesthetist and Occupational Therapist, as well as the hospital and related accounts, including all Radiology claims, have been funded in full according to the benefits available on your selected benefit option, i.e. at 200% of the Scheme Tariff.
There is however a portion of some of the accounts that were not paid in full. These charges relate to either the service providers charging more than the Scheme Tariff (200%), or where the providers billed emergency modifiers that were not relevant in the treatment that you received.
In order for a medical scheme to pay for emergency modifiers, the treatment must meet the legal as opposed to the clinical criteria of an “emergency medical condition” as defined in the Medical Schemes Act:
“….. the sudden and, at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.”
The condition must therefore require “immediate” life-saving treatment and not “urgent” treatment, as was the case with your accident, where the operation took place three days after your accident.
Furthermore, your admission to a private hospital was voluntary, meaning that all claims were not subject to reimbursement as a PMB, but to the extent of the limits applicable to your selected benefit option. This was clearly communicated to you and your service providers prior to your operation.
Genesis has reimbursed all claims in line with your benefit option. We therefore encourage you to contact the doctors and request them to amend / correct their invoices. It may be that you and or your doctors are unaware that all medical schemes are bound to apply the law and the terms of the contract entered into voluntarily by members. The benefit option voluntarily selected by you contains no benefits for emergencies that do not comply with the legal definition.
As much as we would have liked for all your claims to be settled in full, this was unfortunately not possible due to the limits on the benefit option selected by you, but as stated above, your remedy lies with your doctors and not Genesis. Although your treatment (operation) may have been clinically urgent, it does not satisfy the criteria to qualify as a bona fide emergency, in the legal sense as set out in Regulation 7 of the Medical Schemes Act that is binding on you and the Scheme. We trust that our explanation will assist you in understanding why a portion of some of your claims was not paid in full.
Yours sincerely
GENESIS MEDICAL SCHEME
There is however a portion of some of the accounts that were not paid in full. These charges relate to either the service providers charging more than the Scheme Tariff (200%), or where the providers billed emergency modifiers that were not relevant in the treatment that you received.
In order for a medical scheme to pay for emergency modifiers, the treatment must meet the legal as opposed to the clinical criteria of an “emergency medical condition” as defined in the Medical Schemes Act:
“….. the sudden and, at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.”
The condition must therefore require “immediate” life-saving treatment and not “urgent” treatment, as was the case with your accident, where the operation took place three days after your accident.
Furthermore, your admission to a private hospital was voluntary, meaning that all claims were not subject to reimbursement as a PMB, but to the extent of the limits applicable to your selected benefit option. This was clearly communicated to you and your service providers prior to your operation.
Genesis has reimbursed all claims in line with your benefit option. We therefore encourage you to contact the doctors and request them to amend / correct their invoices. It may be that you and or your doctors are unaware that all medical schemes are bound to apply the law and the terms of the contract entered into voluntarily by members. The benefit option voluntarily selected by you contains no benefits for emergencies that do not comply with the legal definition.
As much as we would have liked for all your claims to be settled in full, this was unfortunately not possible due to the limits on the benefit option selected by you, but as stated above, your remedy lies with your doctors and not Genesis. Although your treatment (operation) may have been clinically urgent, it does not satisfy the criteria to qualify as a bona fide emergency, in the legal sense as set out in Regulation 7 of the Medical Schemes Act that is binding on you and the Scheme. We trust that our explanation will assist you in understanding why a portion of some of your claims was not paid in full.
Yours sincerely
GENESIS MEDICAL SCHEME
Best regards,