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Groupe Mutuel denying reimbursements

Navin Sharma Groupe Mutuel 24.03.2019 Melden Reklamation gemeldet

Complaint is concerning the GM Client nos as stated in "Vertrauliche Informationen".


Some background: we were with GM from Jan'12 to Dec'14 (exception being: my son has continued the dental insurance). In Jan'17 - we joined GM again, the whole family this time.


Since, we rejoined - facing one or the other problems. Initially i had to struggle with the GM to continue my Son's dental insurance. Then there were small incidents like GM decided not to pay for Gynae's costs. Had a call with them and they agreed that the mistake is that their side and corrected it (No. 427474024 of 22 October 2018)


Now, meanwhile we shifted our residence from Adliswil to Wettswil in Sep'17. As a result, we started going to new  family doctor. We consulted our agent and was told that on change of address - GM would ask you for new doctor or since address is changed you are entitled for the doctor change automatically (to be honest - it was one of these as I do not remember clearly).


Recently, I am told that since I did not informed GM about the change of family doctor - I need to get a referral letter from my family doctor on their records (which is from Adliswil) and denied any reimbursements.


My wife, went to same Gynae and now for a relatively small amount to be reimbursed - they are issuing a statement that Dr. Ausra is not registered as a Gynae and I need a referral letter. This way they are issuing a contradicting statement. Here is another invoice which was reimbursed - No. 434422467 of 27 December 2018 and No. 428536453 of 12 November 2018.


Other issues:


I was denied reimbursed the dental costs despite of paying the premiums for dental.


I am told that even in case of accidents, I have to bear 10% of the costs.


In general, communication is getting worse as you don't know who is sitting behind the computer and responding to your issue. Whether the person is capable enough to understand and handle complex issues like this or not.


Writing an email to customer care is not bearing any results - hence, I am writing here:


Last mail I sent to them is on 24th Mar'19 on this matter and this is what I wrote -> 


=====


--- Here is my response with this regard:
WIth regard to #1 - I got a response from GroupeMutuel saying that ->
@Dr. Ausra - can pl respond here. AFAIK, we have been told that you are a Gynae and we do not need family doctors referral.


And for #2 and #3 - I got this response ->
I get a feeling that Groupe Mutuel is shying away from its responsibility and communication over email is getting very confusing and time-consuming.
Hence, I requested last time to get me the escalation contact. And, as said - not all bills were denied. Hence, I would have never dreamt of sending a separate communication to GM.
But, as said - you are very adamant that you did not do anything wrong and all is my fault. This is not the right way in my eyes and I would ask for some neutral party to intervene and listen to both sides.
Since, this is a mistake on both side - both sides should bear the costs. WHY ONLY ME?


Hence, I would report this matter and the one above to reklamation.ch, to seek a special help here in the matter.
Pl note, till this matter is resolved - I am not paying you for the invoices you denied to pay for. So, pl DO NOT remind me again or send the invoice again with some reminder charges.


Hope I have made my position very clear.


Thanks and regards,
Navin
P.S. - talking over a phone is better than this written communication which can be interpreted in some different manner. And, I am not showing any disrespect or disregard to what you said. Simply, that it is not the fact.


======


 


Hoping to have a positive response,


Navin Sharma


P.S. attached some responses from GM

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Navin Sharma 16.04.2019

Further update and for the records, I am summarising what was discussed regarding this matter.

On 24th Mar, as announced - Navin reported the matter to reklamation.ch
On 3rd Apr, Navin received a call confirming that Groupe Mutuel is looking into the complaint and informed that Navin would receive a letter from Groupe Mutuel in next coming days and asked to check with Dr. Ausra - if she can write some text to Groupe Mutuel regarding the prescribed medicine is related to Gynae treatment and that it is obligatory for Doctor to provide this information.
On 5th Apr, Neerja and Navin visited Dr. Ausra's clinic to check with regarding what GroupeMutuel has asked to check via telephone on 3rd Apr 1442 HRS.
On 8th Apr, Groupe Mutuel has received a call from Dr. Ausra's clinic and topic has been clarified.
On 8th Apr, Neerja received a call from Dr. Ausra's clinic that they have discussed it with Groupe Mutuel and since our model is HauzArzt - we must get the family doctor's referral - even to visit a Gynae.
On 9th Apr, Ms Theresa from Groupe Mutuel called Navin Sharma and informed that the situation with Dr. Ausra is clarified and apologised for the confusion, on behalf of Groupe Mutuel.

I am told that now onwards, there won't be any confusion w.r.t. Dr. Bäuerle Sven in the capacity of Family doctor for the members of my family (details below). And, Dr. Ausra Sivickiene as a Gynaecologist for Neerja Sharma and Samriddhi Sharma.

And, under "any" treatment for Gynae problems - if Dr. Ausra prescribes any medicine which Groupe Mutuel thinks that is necessary but should be prescribed only by GP (since our model is HausArzt) - Groupe Mutuel will NOT say "Amount not recognized" and will reimburse the payment.

Upon asking by Navin, what if we have this same situation in next few days/months/years. Navin pointed out that, last time also - Groupe Mutuel has declined such payment but upon calling them they agreed their mistake and returned the invoice. And, that he does not want to go through same issue again and again.

Ms. Theresa (on behalf of Groupe Mutuel) assured Navin that she will put a note on our account and Groupe Mutuel's customer representative or corresponding team would be ordered to consider the note before declining any payments.

Navin expressed that this time, since we returned to Groupe Mutuel; this has been the most embarrassing/troublesome and harassing situation. Also, he expressed that he would lookout for the matching krankenkasse to switch away from Groupe Mutuel. Navin also expressed that, he is not sure if the procedure will work flawlessly and we won't have repeat of this issue - just by placing a note!

@Ms. Theresa - should you think that I have interpreted our discussion wrongly - pl feel free to update and circulate the correction. And, add if I might have missed anything!

 

Additionally, not happy with the reimbursement situation around dental expenses.

Ihre Erwartungen
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for other customers, pl do not switch to Groupe Mutuel without proper checks and confirmation on various issues reported around reimbursements. I still DID NOT get any answer to the dissatisfaction shown against the refund policy of Groupe Mutuel.