LY
Linda Y
1 reviews | Active since May 2026
27 May 2026, 15:28
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.
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Replies (3)
EssentialMED's replyOfficial
28 May 2026, 14:40Good day Linda Y,
Thank you for bringing your concerns to our attention. Upon review, please note that the policy does not include the dread disease benefit and the admission was therefore assessed under the illness hospitalisation benefit.
The member initially received approval based on the original quotation provided. Alternative quotations were thereafter submitted from different hospitals with a reduced number of admission days, which resulted in a lower approved benefit amount, as benefits are calculated according to the stated daily hospital benefit applicable to the policy.
Kind regards
EssentialMED Team
Thank you for bringing your concerns to our attention. Upon review, please note that the policy does not include the dread disease benefit and the admission was therefore assessed under the illness hospitalisation benefit.
The member initially received approval based on the original quotation provided. Alternative quotations were thereafter submitted from different hospitals with a reduced number of admission days, which resulted in a lower approved benefit amount, as benefits are calculated according to the stated daily hospital benefit applicable to the policy.
Kind regards
EssentialMED Team
Best regards,
EssentialMED's reply28 May 2026, 14:40
Official
Good day Linda Y,
Thank you for bringing your concerns to our attention. Upon review, please note that the policy does not include the dread disease benefit and the admission was therefore assessed under the illness hospitalisation benefit.
The member initially received approval based on the original quotation provided. Alternative quotations were thereafter submitted from different hospitals with a reduced number of admission days, which resulted in a lower approved benefit amount, as benefits are calculated according to the stated daily hospital benefit applicable to the policy.
Kind regards
EssentialMED Team
Thank you for bringing your concerns to our attention. Upon review, please note that the policy does not include the dread disease benefit and the admission was therefore assessed under the illness hospitalisation benefit.
The member initially received approval based on the original quotation provided. Alternative quotations were thereafter submitted from different hospitals with a reduced number of admission days, which resulted in a lower approved benefit amount, as benefits are calculated according to the stated daily hospital benefit applicable to the policy.
Kind regards
EssentialMED Team
Best regards,
LY
Linda Y's updateReviewer Update
29 May 2026, 08:08Dear EssentialMED Team,
The policy schedule I received on 30 November 2020 clearly states that my monthly premium included cover for accident and illness hospitalisation, emergency casualty visits, dread disease cover (up to R350 000 per member), ICU/high care cover, and permanent disability cover. At no stage was I informed that the dread disease benefit had been removed or amended.
I also did not receive any clear communication or written explanation regarding the assessment of my claim, apart from cession documents requiring my signature. The reasons now provided in your response differ from the wording reflected in my policy schedule, which has understandably caused concern and confusion.
It is furthermore disappointing that meaningful engagement and proper communication only took place after I posted a review on HelloPeter and emailed my intention to terminate the contract. That was the first time I received a direct phone call and genuine interest in addressing my concerns.
Based on my experience, the standard of service, communication, and client support provided has been unacceptable.
The policy schedule I received on 30 November 2020 clearly states that my monthly premium included cover for accident and illness hospitalisation, emergency casualty visits, dread disease cover (up to R350 000 per member), ICU/high care cover, and permanent disability cover. At no stage was I informed that the dread disease benefit had been removed or amended.
I also did not receive any clear communication or written explanation regarding the assessment of my claim, apart from cession documents requiring my signature. The reasons now provided in your response differ from the wording reflected in my policy schedule, which has understandably caused concern and confusion.
It is furthermore disappointing that meaningful engagement and proper communication only took place after I posted a review on HelloPeter and emailed my intention to terminate the contract. That was the first time I received a direct phone call and genuine interest in addressing my concerns.
Based on my experience, the standard of service, communication, and client support provided has been unacceptable.
LY
Linda Y's update29 May 2026, 08:08
Reviewer Update
Dear EssentialMED Team,
The policy schedule I received on 30 November 2020 clearly states that my monthly premium included cover for accident and illness hospitalisation, emergency casualty visits, dread disease cover (up to R350 000 per member), ICU/high care cover, and permanent disability cover. At no stage was I informed that the dread disease benefit had been removed or amended.
I also did not receive any clear communication or written explanation regarding the assessment of my claim, apart from cession documents requiring my signature. The reasons now provided in your response differ from the wording reflected in my policy schedule, which has understandably caused concern and confusion.
It is furthermore disappointing that meaningful engagement and proper communication only took place after I posted a review on HelloPeter and emailed my intention to terminate the contract. That was the first time I received a direct phone call and genuine interest in addressing my concerns.
Based on my experience, the standard of service, communication, and client support provided has been unacceptable.
The policy schedule I received on 30 November 2020 clearly states that my monthly premium included cover for accident and illness hospitalisation, emergency casualty visits, dread disease cover (up to R350 000 per member), ICU/high care cover, and permanent disability cover. At no stage was I informed that the dread disease benefit had been removed or amended.
I also did not receive any clear communication or written explanation regarding the assessment of my claim, apart from cession documents requiring my signature. The reasons now provided in your response differ from the wording reflected in my policy schedule, which has understandably caused concern and confusion.
It is furthermore disappointing that meaningful engagement and proper communication only took place after I posted a review on HelloPeter and emailed my intention to terminate the contract. That was the first time I received a direct phone call and genuine interest in addressing my concerns.
Based on my experience, the standard of service, communication, and client support provided has been unacceptable.
EssentialMED's replyOfficial
29 May 2026, 09:34Good day Linda Y,
Thank you for your feedback. We would like to clarify that your policy does include dread disease cover. We apologise for the incorrect wording used in our previous response.
The assessment outcome was based on the fact that the specific procedure/condition claimed for did not meet the qualifying criteria for cover under the dread disease benefit in terms of the policy rules and definitions. Please contact our claims department as they are urgently awaiting your outstanding documentation in order to proceed with the review and processing of your refund.
We further acknowledge your concerns regarding communication and service delivery throughout this process. It is regrettable that you felt unsupported and unclear about the outcome of your claim, and we apologise for the frustration and confusion this caused. Your feedback regarding communication and client engagement has been noted and will be shared internally for review.
Kind regards
EssentialMED Team
Thank you for your feedback. We would like to clarify that your policy does include dread disease cover. We apologise for the incorrect wording used in our previous response.
The assessment outcome was based on the fact that the specific procedure/condition claimed for did not meet the qualifying criteria for cover under the dread disease benefit in terms of the policy rules and definitions. Please contact our claims department as they are urgently awaiting your outstanding documentation in order to proceed with the review and processing of your refund.
We further acknowledge your concerns regarding communication and service delivery throughout this process. It is regrettable that you felt unsupported and unclear about the outcome of your claim, and we apologise for the frustration and confusion this caused. Your feedback regarding communication and client engagement has been noted and will be shared internally for review.
Kind regards
EssentialMED Team
Best regards,
EssentialMED's reply29 May 2026, 09:34
Official
Good day Linda Y,
Thank you for your feedback. We would like to clarify that your policy does include dread disease cover. We apologise for the incorrect wording used in our previous response.
The assessment outcome was based on the fact that the specific procedure/condition claimed for did not meet the qualifying criteria for cover under the dread disease benefit in terms of the policy rules and definitions. Please contact our claims department as they are urgently awaiting your outstanding documentation in order to proceed with the review and processing of your refund.
We further acknowledge your concerns regarding communication and service delivery throughout this process. It is regrettable that you felt unsupported and unclear about the outcome of your claim, and we apologise for the frustration and confusion this caused. Your feedback regarding communication and client engagement has been noted and will be shared internally for review.
Kind regards
EssentialMED Team
Thank you for your feedback. We would like to clarify that your policy does include dread disease cover. We apologise for the incorrect wording used in our previous response.
The assessment outcome was based on the fact that the specific procedure/condition claimed for did not meet the qualifying criteria for cover under the dread disease benefit in terms of the policy rules and definitions. Please contact our claims department as they are urgently awaiting your outstanding documentation in order to proceed with the review and processing of your refund.
We further acknowledge your concerns regarding communication and service delivery throughout this process. It is regrettable that you felt unsupported and unclear about the outcome of your claim, and we apologise for the frustration and confusion this caused. Your feedback regarding communication and client engagement has been noted and will be shared internally for review.
Kind regards
EssentialMED Team
Best regards,