Disappointed in the service provided by Discovery

Good day,

My husband added me to the Discovery Keycare medical Aid last year. In January the Dr confirmed that I was pregnant and I immediately made contact with Discovery to avoid misunderstandings and implications because I realised that in counting with the Dr's calculations I must have been pregnant when I was added to this cover but did not know because I was still get a monthly period. I was transfered to the Keycare maternity department where the consultant asked various questions which included how far along I was, I was still in a state because this pregnancy was totally u expected and wanted to know where I stand in terms of the medical fund. I was as transparent as possible and answered all the questions as accurate as I can, where after the confirming all the details, the consultant then gave me authorization and and read all the benefits available to me as per her authorization. I was also informed of the network of gynecologist that is available, should use gynochologist that is not on the network, antenatal classes, etc. I've been using the gynecologist on the Discovery network since January and their was no issues but recently when I app**** for hospital authorization, later the consultant from the maternity authorization department returned my call stating thy won't be authorizing the claim due to me being over 12weeks and I will have to repay all my gynecologist visits,I explained that I was only making use of this facility as per authorization given by Discovery, honestly speaking of we knew about this we would have temporary suspended my medical aid for this time period is it would not make sense to pay cash for a gynecologist and pay a monthly medical aid of more than R1500, I feel that we have been mislead.

I explained my situation to the consultant and was given the option to appeal. 4th March I received a letter addressed to my husband via email dated 27th April 2020, stating that they will not cover my pregnancy due to the condition existing prior to joining but my question is why was authorization given in January and why did the consultant in the maternity department not inform us of this clause and why did they allow us to make use of the gynecologist benefits, why only wait till I apply for hospital authorization,now Discovery is requestioning that I repay them for the authorization given to me by Discovery maternity department. I then sent an appeal 4th March to the Discovery Forensic department as informed by the consultant and got a respond that they will look into the matter and contact me within 5 days.

The following week I called, 12/13 March because there was no response from Discovery. The consultant informed that they will contact me she's sending an email to the relevant person working on the case and I explained to her that am worried cause its almost my due date and I've made no alternative arrangements and need to know where I stand cause it's short notice, she said they will contact me before end of business. I then waiting but they failed to contact me. 19/20 March I called and the agent confirmed that it's way overdue and this matter had to be sorted as it's way overdue, she said she will have the relevant guy working on the matter contact me the same day but no one made contact, it became quite frustrating and 21st March I emailed Discovery again. 23rd March they responded they will contact me in 5 working days. 3rd April I called again, the consulted ensured me she will have the relevant person contact me the same day and set it as a matter of urgency because she can see this is way overdue and I have not been assisted on this matter and there has been no movement.

I later received a email from Jarrod Chetty, who informed as per Dr Theodore D Kretzmar informed that they will not be covering the pregnancy,stating if I informed the cover when joining it would have been on the system, this is after I explained on a few occasions that my pregnancy was confirmed in January and I was unaware of my pregnancy also that I was transparent and contacted Discovery maternity department as soon as it was confirmed and that after I informed them and gave them the necessary information, i was then given the authorization, at no given point have I failed to inform Discovery of any information,and as for their consultants in the maternity department, I'm sure they are should be aware of the clause and authorization benefits and this is their product they specialize in and is also the reason why she asked and confirmed the necessary pregnancy informaion with me asking how many weeks I am etc. The consultant also confirmed that the calls are recorded, now that I am requesting for the calls it is said that the calls are not routed to underwriting and that the agent was only advising me as per the general information on the system and had I informed Discovery prior to the date it would have been on the system.

Can you please inform what would be the correct procedure to follow, because Discovery maternity department has given us authorization for the maternity benefit and we were unaware of the clause and it was only made known to us on request for hospital authorization, and they now want us to repay them for the authorization given by them. During this time of lockdown where do we get funds to cover the hospital fees that has already been booked a few months ago. I don't believe at any point that we withheld information or misinformed Discovery but I do feel that they mislead us. Please inform if I can refer this matter to the Ombudsman and CMS. It's really disappointing.