A pharmacist who allegedly defrauded members of the Government Employees Medical Scheme (GEMS) of almost R1 million by promising them Green Cross shoes will appear for the first time in the Giyani Specialised Commercial Crimes Court (SCCC) for possible pre-trial talks on Thursday, 29 May 2025.

Limpopo police spokesperson Malesela Ledwaba confirmed the accusations against Tinyiko Gift Mangolele, stating GEMS was defrauded of R910,000.

Ledwaba further disclosed that the investigation into Mangolele’s actions is still ongoing. The Malamulele pharmacy owner is accused of using two doctors’ information to make false claims for prescription drugs without their consent.

“During the month of April 2024, the Government Employees Medical Scheme (GEMS) opened a case for investigation of fraudulent claims made by the suspect after contacting a medical aid member to provide their details with a promise of giving them a cash back and also an option of getting Green Cross shoes,” Ledwaba said in a statement.

“Through intensive investigation conducted, it was further established that other members of GEMS never consulted with the doctors, but claims were made on their behalf. As a result, the medical aid suffered a total loss of nine hundred and ten thousand rands (R910,000.00) between January 2018 and September 2022,” he added.

National Prosecuting Authority (NPA) regional spokesperson in Limpopo, Mashudu Malabi-Dzhangi, confirmed on Wednesday that the case has been transferred from Malamulele Magistrates Court to the Specialised Commercial Crimes Court, noting that such cases are processed in a delicate manner.

“Malamulele is a normal court for all matters, but for fraud and corruption, the trials are conducted in the Specialised Commercial Crimes Courts. But the trial will not start on that day(29 May 2025); it can be for arrangements of pre-trial. We don’t know what is going to happen because that will be between the lawyers and the prosecutors. What about if they make an application that we are not proceeding? I can’t assume they (lawyers) will take this route or the other. All I want is to stress that all matters of fraud or these types of cases are not tried in the ordinary court. They are tried in the Specialised Crimes Court, so for cases appearing for the first time in court, one cannot say that these people are going to do this. They can bring an application that there is no case,” Malabi-Dzhangi said.

Mangolele is currently out on bail after the Malamulele Magistrate Court granted him a R5,000.00 bail.

According to information available online, medical aid scams in South Africa involve various fraudulent practices where individuals or healthcare providers intentionally mislead medical schemes to gain unauthorised financial benefits. These scams range from submitting false claims for services never rendered to colluding with doctors and hospitals for inflated admissions. They also include misuse of benefits, such as claiming for non-covered services or using multiple gap cover schemes for the same claim.

Here’s a more detailed look at some common types of medical aid scams:

1. False or Inflated Claims:

• Forging claims: Submitting claims for services that were never provided.
• Collusion with providers: Working with doctors or hospitals to inflate claims for hospital admissions that never occurred.
• Submitting claims for non-covered services: Claiming for services that are not covered by the medical scheme, sometimes using codes that are covered.
• Billing for generic medication as branded: Providing a member with generic medication but charging for the branded version.
• Providing unnecessary services: Offering services that are not medically necessary and claiming for them.

2. Misuse of Benefits:

• Using a member’s card for unauthorised dependents: Providing benefits to dependents who are not covered by the member’s plan.
• Dual memberships: Attempting to claim from multiple medical schemes for the same services.
• Multiple claims for the same product: Claiming multiple times for the same physical device or product and profiting from the excess.
• Gap cover fraud: Submitting gap cover claims after having paid out of pocket for the same valid claim, and claiming from both the medical scheme and the gap cover provider, or using multiple gap cover schemes for the same claim.

3. Card Farming:

• Unauthorised use of a member’s card: Providing a member’s card to someone who is not entitled to use it.
• Lending a card to others: Providing a card to others to receive benefits.

4. Organised Fraud:

• Syndicates: Organised groups that work together to commit medical aid fraud.
• Card farming: Using multiple member cards to claim for the same services.
• Fraudulent medico-legal claims: Submitting claims for medico-legal issues that are false, including false birth injury claims.

5. Other Types of Fraud:

• Submitting claims for deceased patients: Submitting claims for individuals who have passed away.
• Fraudulent claims in Covid-19 days: Claims that were submitted during Covid-19 days that were later found to be fraudulent.
• Fraudulent billings: Submitting claims with inaccurate codes or information.
• Card farming: Using a member’s card to receive benefits for someone else.