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When a generous and selfless heart triumphs over greed

Mrs Lebo Montshiwa of Mahikeng waited more than five years to see justice done and to do right by her medical scheme, GEMS.

In December 2007, Mrs Lebo Montshiwa noticed that a number of items that had never been dispensed to her by her local pharmacy had somehow found their way on to her GEMS medical scheme statement. Being the honest, hard working woman that she is Ms Montshiwa immediately contacted Omphemetse Pharmacy to find out what happened and to ask that the mistake be corrected.

The owner of the pharmacy, Ms Tshegofatso Maubane, explained the list of additional charges away by telling Mrs Montshiwa that it was standard practice to charge additional items to the medical scheme accounts of members rather than charging levies to individual medical scheme members.

As a concerned and proactive GEMS member Mrs Montshiwa was not happy with this explanation at all. After all, her medical scheme and all its members were being wronged! To her it just did not seem the honest and right thing to be doing. What if every GEMS member did this? Where would it leave the Scheme and its members in times of real need?

Without thinking twice she immediately contacted her medical scheme to voice her concern. She did so by calling the GEMS call centre and ultimately lodged a complaint using the GEMS fraud line. It was at that very moment that the wheels of justice, which finally ended in the sentencing of Mrs Maubane to four years imprisonment, suspended for three years, clicked into motion. The pharmacist was fined R20 000 along with the suspended jail sentence.

During the extensive investigation that followed it was revealed that Mrs Montshiwa's friendly neighbourhood pharmacy submitted as many as 114 fraudulent medicine claims amounting to tens of thousands of rands to GEMS during December 2007 and February 2009. The dishonest pharmacist was falsifying invoices from pharmaceutical companies so that she could submit additional, fraudulent claims to the Scheme.

She was finally arrested on 11 February 2013 and was sentenced on 22 February 2013 after pleading guilty. In his judgement Magistrate Thabo Lephadi said: "Just like corruption, fraud is a very serious offence. You do not just wake up one day and say: ‘I am going to commit fraud today'. Committing fraud takes careful planning. It takes time to execute such a plan. And it deprives a member of the public that supports your business."
 
In order to take action against the pharmacist GEMS needed the help of the brave and righteous Mrs Montshiwa. As a good human being and an honest GEMS member she did not hesitate to do the right thing. She also courageously and diligently followed through on her initial complaint and saw the court case through to the bitter end.

The commitment demonstrated by Mrs Montshiwa was nothing short of exceptional and this was instrumental in GEMS securing a favourable judgement which also resulted in the Scheme securing an adverse ruling against the pharmacy by the South African Pharmacy Council and the Appeal Board of the Council for Medical Schemes.
 
Sound evidence and ample proof are of immense importance in obtaining a favourable judgment. The cooperation of a witness is imperative as are members who will not look the other way when a dishonest or fraudulent act is committed. Because Mrs Montshiwa did not look the other way, and because she was willing to give testimony when it was needed we were able to pursue the case against the pharmacy to the end. In the process justice was done.

The matter was brought to the attention of the Council for Medical Schemes and the South African Pharmacy Council to ensure that the pharmacist would be stopped in her tracks the minute she tried to commit fraud again.

When the Executive: Contracts and Operations of GEMS heard of the sentencing of Omphemetse Pharmacy in Mahikeng at the end of February this year she proudly remarked: "Behind this story is a very strong member who is truly an asset and an attribute to her medical scheme."

Contact the GEMS fraud zone
If you know of any fraud taking place or being planned, put an immediate stop to it by calling the anonymous 24-hour toll-free GEMS Fraud line on 0800 21 22 02. You can also send an email to [email protected] or send a fax to 086 726 1681.
Information can also be posted to: The Fraud Services Manager
PO Box 21076
Valhalla
0137.

*Please note that the name of the member has been changed in order to protect her.