Claim rejected as an excluded service: what to ask
Your medical scheme says its rules exclude this service from cover. What that means, and the questions to put to the scheme in writing about the exclusion.
The scheme says its rules exclude this kind of service from cover.
The wording to look for
- “a general exclusion applies”
- “is excluded in terms of the rules”
- “not covered under this option”
Questions to put to your scheme in writing
- Which exclusion in the registered rules was applied to this claim?
- Please provide that exclusion as it appears in the rules registered for the current year.
- Does the scheme apply that exclusion where the service is a Prescribed Minimum Benefit, and how was that assessed?
- When was that exclusion last amended, and was I notified of the amendment?
Only you can answer these
- Whether the service was part of treating a condition you have registered.
Paste your rejection notice and build the letter. It is read on your own device and never uploaded.
See every reason a South African medical scheme gives.
Pryse is not a law firm and does not act for you. Nothing here is a determination of your rights or legal advice, and no registered scheme rule is quoted. The questions ask your scheme to provide its own.