Claimed not paid because their health partners had no knowledge of the benefits and they are making me liable for the claim

have dispute with Discovery Medical Aid Scheme. My daughter on the 06 May 2018 fell on a sharp object while running in the field. She had a deep wound that needed stitches. I then went to Melomed Hospital the same evening and I was advised that its R1800 and medical aid did not cover that. The nurse had a look at the wound and said it needed to be stitched in within the 24 hours from the time she fell. I then went to the doctor on the 07 May 2018. The doctor had a look at the wound and he said it needed to be stitched. He asked the assistant to contact Discovery to ask if it was to be covered. The assistant Sonia, called discovery and spoke to a person by the same of Lusanda. Then I was advised that the procedure was not covered and as a parent and being advised that the wound had to be done and not to risk infection, I asked how much does the doctor charges he said R1200. I then made the payment and the doctor gave her stitches and medication. He then submitted the consultation claim for Swazi as well as for myself as I was also not well. Around the 9th May 2018, I sent an email to discovery and complained and the person who responded just sent a spreadsheet of classic smart sport benefit codes and nothing about the sport benefit needing to be activated.

I forwarded the spreadsheet to the doctor and Sonia(the assistant at the GPs office),tried to claim and called me and said the codes on the spreadsheet was not being accepted by their system. I then said to her she must sent it to me and will forward to discovery. I forwarded the invoice and letter confirming from the doctor on the 14th or 15 May 2018. I then followed up and spoke to a helpful lady by the name of Unathi, she said I must give it two days for the claim to be processed and that she will try and check but because she is almost due on her pregnancy if I do not hear anything till Thursday, I must then call back. I called back Thursday spoke to another helpful guy by the name of Lusanda, I was on the phone for 20 minutes, he advised that the sport benefit needed to be active and that he tried to call the doctor and advise him but he is not in and will try the next day. He advised that I need to give consent to the GP so when is it being done I will receive an sms. Friday the 18th May 2018, still nothing, I called the GP office and advised on what needed to be done on their side. This is the first time they heard of it, called discovery and had an online chat and all I was told basically is that they cannot contact the doctor and the GP must contact them if they not able to do this, I then advised the doctor’s office and provided them with the number they had to call. GPs office was struggling with this, I called again I spoke to someone who said there were no benefits for this, he did not even say something about sport injury benefit, I then asked to speak to a Manager Freddie and told her off all of the communication she was also adamant that there was not cover and we were about to debate if running was a sport as she said, “running could be considered a sport and I told her running is a sport”. She was also adamant that in the call centre it was all general queries and no one knows how to activate the classic smart sport injury benefit therefore no one can call the GP and assist but I told when I spoke to Lusanda, he was able to give explain and had tried to call the GP. During the call, I received the call from my GP to say that they are activating the benefit and so I told Freddie and hang up. Monday 21 May 2018, I call and wanted to know the status of the claim. I spoke to someone who said that it was not captured and injury benefit is not yet activated. I asked to speak to the Manager and was transferred to Unathi.

She assured me she would resolve this by the end of the day, to summarise,she called the GP and the injury benefit had been actived and auth code for the specialist had been provided. Now here is the problem discovery will only be paying for this if I am going to the specialist.The procedure had been done on the 9 th May 2018. My argument is that;

Discovery is that the assistant at the GP office when they claimed they asked if the procedure was covered and they did not mention that they wanted to activate the injury benefit , Unathi advised that the health partner have said it is not their role to go beyong the question answered, so as much as they had been told the client is on classic smart and fell while running there is no way they would have told the GP that the member is covered under the injury benefit that needed to be activated Discovery network GPs have not been educated and given enough knowledge of the medical aid and benefits. That in this case has disadvantaged me and is expected that I pay the costs. How does discovery decide which GPs, Hospitals and Specialist? Since in this case even if the Melomed and the GP could have actived the injury benefit and this code have done the first time. Does discovery give their doctors workshops and tutorials on the plans to ensure that we as client do not get the bad end of the stick. Where is my peace of mind Discovery medical aid is not willing to communicate with their partners and there is no accountability? As a member of discovery should I accept that I will be playing middle man between health partners and discovery. I would have no problem if the injury was not covered, In this case it is, It is just lack of knowledge and information on the HealthPartners that have gone through a process and being selected by discovery to be the network providers. Am I liable for the lack of the information that your healthcare provides are not given and the lack of service from your consultants? I am disputing this claim and do not think I should be liable for. The reason I pay medical aid is because I want a peace of mind that when accidents happen, I will be covered and not the nonsense that I have been given, I am considering other medical aid, that are more driven by empathy.