Linda Y

ESSENTIAL MED – INADEQUATE COVER FOR MEDICAL PROCEDURES

In December 2025, I was diagnosed with a brain tumour and app**** for authorisation for a craniotomy in January 2026. After submitting a hospital quotation of R547 000, Essential Med approved only R63 600 for 3 days of post-operative ICU care and required me to accept liability for the remaining balance. I appealed this decision but received no response. I then submitted a lower hospital quotation of R421 000, yet the approved cover was reduced even further to R42 400, now covering only 2 days of ICU care. This left me with a shortfall of R378 600. The procedure was ultimately performed at a State hospital at minimal cost. However, my subsequent claim was rejected due to alleged insufficient paperwork from the State hospital. I have been a claim-free member for 5 years. My approved cover did not include any in-hospital procedure involving specialists or theatre costs. It is also concerning that the approved benefit decreased as the hospital quotation decreased for the same procedure. Be warned: this product does not provide meaningful financial protection in a serious medical situation.