Bad service due to non payments

Dear [Discovery Medical Aid Representative],

I am still awaiting a response to my previous emails regarding the payment for Dr. Burger’s MRI and the neck brace. This delay is unacceptable, and I need this matter resolved immediately.

This procedure was part of in-hospital cover, yet I am now being informed that it is not covered. How is this justified? We are required to pay exorbitant monthly premiums, but when we need to rely on the medical aid for essential procedures, we are met with denials and delays.

I expect an immediate explanation and resolution. Please confirm urgently how this matter will be addressed, as further delays are not acceptable.

Awaiting your prompt response.

This is the issue i have ?
Discovery sends documents that i dont understand


Well we pay so much every month and being admitted to Hospital for the 2 procedures which where supposed be covered by In hospital cover and not covered ????????????

How was the MRI authorized after i was admitted to hospital and then after the MRI was done i am now being told that i have to pay a short fall


From my Understanding if any Procedure is done when admitted to hospital , the procedures are covered by the Hospital cover

i would need to get a senior manager to call me before i go legal with this

Dear Discovery Medical Aid,

I am writing to express my deep frustration and disappointment regarding the ongoing issues with my medical claims, your lack of communication, and your continued failure to provide clarity and accountability.

To date, I have not received a single call from a manager, despite my repeated and urgent requests. This level of disregard is completely unacceptable, especially considering the seriousness of the matter at hand.

I am now being informed that a recent in-hospital claim – specifically for anesthesia – will not be paid. Your representatives claim this was a “planned procedure” and that the anesthetist involved is not part of the Discovery Plan. If that is the case, I ask the following:

The responsibility lies with Discovery to inform and authorize correctly. I should not be penalized for internal miscommunication or system failures. The current outstanding claims, which now total approximately R9,000, are causing severe financial and emotional stress. Your silence and lack of escalation on this matter are unacceptable. If this issue is not resolved immediately, I will be forced to take further action, including:

I expect a call from a senior manager within 24 hours and a clear breakdown of how Discovery plans to resolve this matter. Sincerely,

Well i better get This resolved at the earliest as my Patience is growing thin ,
This matter has been Dragged on for to long by Discovery ,

Take this Seriously as i will go to the media and Ombudsman

Dear Discovery Medical Aid,

I am writing to formally escalate the ongoing issue regarding the refusal to pay for an MRI that formed a critical part of an in-hospital procedure which was authorized and carried out under emergency conditions.

As per the Medical Schemes Act 131 of 1998, specifically under the Prescribed Minimum Benefits (PMBs) framework, medical schemes are legally required to cover the diagnosis, treatment, and care of emergency medical conditions, regardless of the specific plan a member is on. My condition, involving severe pain and neurological risk associated with cervical vertebrae C4–C6, constituted a clear Emergency Medical Condition, as defined in Regulation 7 of the Act.

The sequence of events is as follows:

Dr. Rauf has also submitted written correspondence to Discovery, outlining the medical necessity of the procedure and the associated imaging, yet this has not resolved the matter.

In light of this, I request the following:

Should this matter not be resolved within 7 working days, I will be compelled to lodge a formal complaint with the Council for Medical Schemes (CMS), as per the rights afforded to me under the Act.

Please treat this matter with the urgency it deserves. I look forward to your prompt response.

Dear Ms Laurian Simon,

Thank you for your response dated 30 April 2025.

I refer specifically to the assertion that the MRI was not conducted on the date of surgery. Kindly be advised that this is factually incorrect.

The MRI was performed on the same day as the surgery, namely 18 March 2025, not a week prior as erroneously suggested in prior correspondence. From my recollection and according to the treating surgeon, the MRI was conducted approximately one hour prior to the surgery, and its purpose was to guide the operative planning, which would not have proceeded without it.

Therefore, I formally request that you review the hospital records for 18 March 2025, including imaging logs and surgical notes, to confirm the MRI was conducted on the day of admission for surgery, not during a prior admission for unrelated lumbar treatment.

The implication in your response that the MRI was related to a previous admission is not only factually incorrect but mischaracterizes the clinical context under which the MRI was conducted. It was directly related to the cervical spine pathology requiring surgical intervention and not to any lumbar condition.

Failure to acknowledge and correct this fundamental error constitutes a misrepresentation of clinical facts and may result in prejudicial treatment under your benefit rules.

I remain committed to resolving this matter amicably but reserve all rights to escalate to the Council for Medical Schemes should this factual inaccuracy remain uncorrected.

Dear Laurian Simon and Discovery Health Medical Scheme,

Good day,

I refer to your correspondence dated 2 May 2025 and wish to place on record my formal dispute of the claim processing related to my medical treatment in March 2025.

I categorically dispute the dates recorded on Discovery’s system as follows:

Furthermore, as per Regulation 5 of the Medical Schemes Act, all claims must be paid accurately and fairly, in accordance with both the Scheme Rules and the factual clinical service dates. The assertion that Discovery "cannot offer an opinion" on discrepancies in provider billing dates is a dereliction of responsibility under section 29(1)(o) of the Act, which obliges the Scheme to ensure accurate administration and fair benefit application.

Given the persistent contradictions in your responses and the evident failure to process claims based on the accurate date of service (18 March 2025 for MRI), I have no alternative but to escalate this matter legally.

Please take note:

Yours faithfully,
Mr. S. Naboe

Good afternoon,

Further to my previous correspondence, I would like to clarify a point I had unintentionally misstated in an earlier email.

I initially indicated that I had not been to Arwyp Hospital. However, upon reviewing my records and email correspondence, I can confirm that I did, in fact, attend Arwyp on 11-03-2025 for a pain management procedure (injections) administered by Dr Rauf, which was medically necessary and a prerequisite to the scheduled surgery.

I sincerely apologise for the oversight and any confusion this may have caused.

In light of this clarification, I am formally requesting that the necessary special authorisation for the procedure now be reconsidered and processed, so that the related payment can be facilitated. Given that this was part of a pre-surgical treatment plan, I trust that Discovery will take this into account and reassess the claim in good faith.

I would also like to bring to your attention that important correspondence regarding this matter may have been sent to an incorrect email address. My correct email address is ***, and Discovery also has my alternative email ***, as well as my mobile number, on record. If any notifications were sent to an invalid address, I believe the server would have returned them as undelivered.

Furthermore, from my emails and phone conversations with your team, at no point was I advised that a special authorisation could have been requested in advance. I would appreciate an explanation as to why this was not communicated to me earlier, despite several attempts on my part to engage and clarify the matter.

@Esmarie – While I acknowledge that we had a phone conversation, I must point out that at no time during that call was I advised of a required co-payment or any pending arrangements regarding payment for Dr Rauf’s procedure.

I respectfully request that this issue now be urgently reviewed and addressed. Please confirm if any additional documentation is required from my side to assist with resolving the matter promptly.

,

Good afternoon,

Further to my previous correspondence, I would like to clarify a point I had unintentionally misstated in an earlier email.

I initially indicated that I had not been to Arwyp Hospital. However, upon reviewing my records and email correspondence, I can confirm that I did, in fact, attend Arwyp on 11-03-2025 for a pain management procedure (injections) administered by Dr Rauf, which was medically necessary and a prerequisite to the scheduled surgery.

I sincerely apologise for the oversight and any confusion this may have caused.

In light of this clarification, I am formally requesting that the necessary special authorisation for the procedure now be reconsidered and processed, so that the related payment can be facilitated. Given that this was part of a pre-surgical treatment plan, I trust that Discovery will take this into account and reassess the claim in good faith.

I would also like to bring to your attention that important correspondence regarding this matter may have been sent to an incorrect email address. My correct email address is ***, and Discovery also has my alternative email ***, as well as my mobile number, on record. If any notifications were sent to an invalid address, I believe the server would have returned them as undelivered.

Furthermore, from my emails and phone conversations with your team, at no point was I advised that a special authorisation could have been requested in advance. I would appreciate an explanation as to why this was not communicated to me earlier, despite several attempts on my part to engage and clarify the matter.

@Esmarie – While I acknowledge that we had a phone conversation, I must point out that at no time during that call was I advised of a required co-payment or any pending arrangements regarding payment for Dr Rauf’s procedure.

I respectfully request that this issue now be urgently reviewed and addressed. Please confirm if any additional documentation is required from my side to assist with resolving the matter promptly.

,

Extremely Bad Service
Initial conversation started off with incorrect information and Procedure Dates,
Then changed to before operation
Was not advised of no coverage when in hospital
incorrect e mail used
e mail only updated when i had let them know that the details are no correct

Lawyers are no handling this and will take it from here on and all Legal cost to be billed back to Discovery and for time ?

Dear Discovery Medical Aid,

Kindly advise if any payment is scheduled to be made. If not, please ensure that all further communication regarding this matter is sent via email only, as the case has now been handed over to our legal representatives for further handling.

We request that no telephonic communication takes place moving forward and that all correspondence be directed in writing.

Thank you for your attention to this matter.

Discovery has Finally made payment that was to be made for the Fees Owed to Dr Burger for the MRI ,
Payment was only made after i lodged a complaint with the Ombudsman ,

My Lawyers tried calling Discovery to find out what will happen with the monies deducted from my savings whilst at Admitted at Arwyp and call gets cut

i tried calling back been provided a 1 time Pin 9328 & 1846 with no assistance ,
Voice Prompts tell me to hold for the Next agent and call just drops ,

Once Again Discovery ,
Its been a fight with Discovery and not paying service providers , not checking if all ICD codes are correct , Not querying a clients claim

why had i have to go to the Ombudsman to have this issue resolved and get lawyers involved

I wish to formally lodge a complaint regarding Discovery Medical Aid’s handling of a recent claim, which was only paid out after I escalated the matter to the Council for Medical Schemes and involved legal representation.

Despite having submitted all required documentation timeously and in accordance with scheme rules, the claim was unreasonably delayed — with no resolution until external pressure was app****. This behavior caused me significant stress, anxiety, and emotional hardship, particularly given that the claim involved [briefly describe the type of treatment or urgency].

As a result of Discovery’s failure to act in good faith and fulfill their contractual obligations promptly, I experienced:

I am therefore requesting:

If this matter cannot be resolved amicably, I reserve the right to pursue a delictual claim in civil court for emotional distress and breach of duty of care.

Dear Discovery Medical Aid,

RE: Ongoing Delay in Refund / Claim Mishandling and Emotional Distress

How long is this expected to take? The delay is unacceptable and reminiscent of the previous incident where your company failed to acknowledge liability for fees relating to my hospital admission.

As a direct result of Discovery’s failure to settle amounts due to the service provider:

This caused me undue stress at a time when I was meant to focus on healing. Your company’s negligence has impacted both my personal dignity and professional standing. I am now requesting the immediate refund of my medical savings – today – without any further delay. Once this is completed, I expect a direct call from a consultant confirming the refund has been processed and reflects . Additionally, I require clarity and written confirmation regarding whether physiotherapy sessions will be covered. Due to the ongoing uncer*****y and lack of transparency, I have had to defer necessary treatment, which may further compromise my health and recovery. Please treat this matter with the seriousness it deserves. Should there be any further delay, I will proceed with lodging a formal complaint with the Council for Medical Schemes (CMS) and will be seeking legal advice to claim compensation for:

I expect a response and resolution by end of day today. Yours sincerely,