Discovery claims my mum must pay R8875 for all errors made by discovery themselves.

<p>Mum Has been a member since 2011 on coastal core. In 2014 she had a major operation and was diagnosed with stage 3 c uterine cancer, an aggressive cancer . Discovery registered her for the oncology programme on 9 Sept 2014. Once a member has a chronic illnes, the member is flagged. The oncologist sent in a detailed treatment plan in nov 2014 and the entire treatment plan was approved, AUTHORISATION NO ********** 9 Mums plan was upgraded to Classic comprehensive with zero msa effective 1 Jan 2015. Because mum was flagged due to a chronic illness as per discovery, all her information including her treatment plan should have automatically been transferred to her upgraded plan. Discovery failed to do this causing infinite problems. </p> <p> </p> <p>Hadiyo Tshabalala has claimed she has done an investigation. her investigation is not thorough as she would have picked up all the errors made by Discovery. She would not have given me a summarised explanation for each debt as all the debts are not related to their failure to transfer mums info to her upgraded plan. Her explanation is unacceptable especially since a thorough investigation was not done.</p> <p> </p> <p>Firstly They did not load mums treatment plan on her upgraded plan , and due to this some items were rejected and some items were paid using the same authorisation ********** 9. The chemotherapy service fee for 5793 & 5794 was rejected each week but it was on the authorised treatment plan ********** 9, they paid The supporting drugs, materials and fluids for each week of chemo using ********** 9 but just chose not to pay the chemotherapy service fee, Why not??.They claim that the benefits were not loaded but how is it they paid other benefits using ********** 9? in mar 2015 a discovery backdated mums benefits to apy from jan 2015. The exact same treatment plan was provided again. </p> <p> </p> <p>We do not have a money tree discovery. These are your errors which you made. Is it your business prectice for members to pay for debts which you incurred by your self.</p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p>Then mum was hospitalised in jan 2015. Its an in hospital benefit which was processed incorrectly and sent to the self payment gap pushing mum into a false annual threshold benefit, purely no fault of my mum. This occurred for both Dr. Pirjol & for ampath, both were in hospital benefits incorrectly processed for mums admission 28 jan 2015 - 30 jan 2015.</p> <p> </p> <p>Then Qestmed, the pharmacy. They paid qestmed from the initial authorisation on 19 jan 2015 but didnt pay for chemotherapy dervice fee for Dr. Pirjol. They short paid qestmed, did numerous endless reversals , they did not what they were doing, purely no fauklt of my mum. The short payment was sent to the self payment gap pushing mum into a false annual threshold benefit.</p> <p> I have been trying to get proper answers since 2015. in between i fell ill many times and could not take this up again. in aug 2016 i emailed health info asking for each debt as per there debt summary sheet to be explained. Hadiyo Tshabalala responded but she also explained a query about a different issue regarding ampath. We ended up paying cash to ampath, discovery refused to pay that, but this was not what i queried in aug 2016.</p> <p> </p> <p> </p> <p>Below is the email she sent 16 Sept 2016. </p> <p>Dear Mrs Allim</p> <p> </p> <p>I trust that you are well.</p> <p> </p> <p>We have tried calling you on ********** and on ********** , however you were unavailable to take our calls.</p> <p> </p> <p>We received a request from your Healthcare provider to contact you regarding the amount owing to the Scheme of R 8875.00 claim reversals.</p> <p> </p> <p>The amount owing was created as follows:</p> <p> </p> <p>Amount<br />Treatment date<br />Process date<br />R 191.20<br />30 January 2015<br />18 June 2015<br />R 8242.50<br />05,12 and 19 January 2015<br />08 June 2016<br />R 288.80<br />16 February 2015<br />26 March 2015<br />R 152.50<br />30 January 2015<br />09 March 2015<br /> </p> <p>We can confirm that you were on your daughter’s membership up until 31 December 2014 after which you app**** for your own membership effective 01 January 2015. You selected the Classic Comprehensive Zero MSA plan and due to an unforeseen error, your Oncology benefits were not transferred to your new membership upon activation. This resulted in the Oncology related claims being accounted for against the incorrect benefit. Even though these claims rejected due to it not having a Medical Savings account (MSA) component, they were accumulated towards the Annual Threshold amount of R12 590. Once you have reached this amount in claims, the Above Threshold Benefit (ATB) kicks in. The ATB is an out of hospital benefit which supports you in funding most day to day claims. You accessed the ATB in February 2016 and the aforementioned claims assisted you in reaching the ATB.</p> <p> </p> <p>When it was established that your Oncology benefit was not transferred, this was corrected and the benefit was loaded on 23 March 2015 but cover was backdated to 1 January 2015.</p> <p> </p> <p>The respective oncology claims were then reprocessed from the Oncology benefit. This is when the amount due to the Scheme was generated as the oncology claims had been accounted for against two different benefits. The Scheme could also not remove you from the ATB as you were benefiting from cover for day to day claims. The Scheme funded R58 802.68 in day to day claims from the ATB for 2015 and you would have not received this amount in benefits had the clawback amount not assisted you in accessing the ATB.</p> <p> </p> <p>I am sorry that I am not able to provide you with the desired outcome; however trust that I have adequately explained how the amount owing to the Scheme came about. </p> <p> </p> <p>In the event a member feels that the Scheme is breaching it legal obligations, he/she may approach the Regulator, the Council for Medical Schemes for assistance. You may do so in writing to Council for Medical Schemes Complaints Unit, Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157 or email ********** Customer Care Centre: ***/ website www.medicalschemes.com.</p> <p> </p> <p>Regards</p> <p> </p> <p>Hadiyo Tshabalala</p> <p>Executive Relationship Manager</p> <p>Discovery Health (Pty) Ltd <br />On behalf of Discovery Health Medical Scheme</p> <p>Tel +27 11 ********** </p> <p>Fax +27 11 ********** </p> <p>Email ********** <p>Website: www.discovery.co.za</p> <p> </p> <p>I rep**** to her today. Reply is as follows..</p> <p> </p> <p>Hi</p> <p>I find it absurd that a member should pay for Discovery's errors. Your explanation for this self incurred debt is unacceptable especially since a thorough investigation was not conducted by you. Why exactly should member pay for errors that discovery made?? Discovery incorrectly processed the claims and pushed into the spg, how is this the members fault ??</p> <p>What day to day expenses were paid from the scheme?? Mum was only treated by oncologist and was admitted three times in 2015 in Jan, May & Sept. . In Aug 2015 she had seen a GP. Mostly pathology was done which oncology covers. It was found that chemotherapy caused a blood clot in her thigh and ultrasounds were done well after discovery erred and didnt pay from the oncology benefit as was supposed to have been done in the first place.<br />Forward a detailed breakdown R58 802.68 in day to day expenses. Mum didnt utilise any other sevice besides in hospital benefits and oncology and a compression stocking was ordered for the blood clot caused by chemo.</p> <p>THE FOLLOWING IS WHAT YOU FAILED TO PICK UP ON YOUR INVESTIGATION, ALL ERRORS MADE BY DISCOVERY.</p> <p>Firstly mum was diagnosed on 9 sept 2014, She was also registered for the oncology benefit on 9 sept 2014. Once you have a chronic illness the member is automatically flagged. Mum was on coastal core until 2014. She was upgraded in 2015 to classic comprehensive zero msa plan. Mum was already flagged in 2014 for cancer, her records and all treatment plans should have been automatically transferred to the new plan as she was flagged with a chronic illness in 2014, this did not happen as someone erred on discoverys side. </p> <p> </p> <p>Secondly i have reviewed in detail all the transaction histories for all service providers with regards to the claim, have also been through the treatment plan submitted in 2014 and also been through the discovery approved treatment plan. It clearly shows the person responsible really did not know what they were doing. Why are *********** people employed in such a huge company thereby making the members lives hell ? The treatment plan was was submitted in 2014 and All items on the treatment were exactly approved check AUTHORISATION NO. ********** 9, nothing was rejected from the treatment plan. As per treatment plan, discoverys authorisation ********** 9 expressly includes the CHEMOTHERAPY SERVICE FEES, CHEMOTHERAPY DRUGS, SUPPORTING DRUGS, MATERIALS & FLUID AND DISCONTINUED CODES. Compare the treatment plan to discoverys approved benefits, everything matches perfectly to the treatment plan. </p> <p> </p> <p><br />REFER TO CLAIM TRANSACTION HISTORY FOR DR. PIRJOL FOR 2015, R R 8242.50 - STUDY THE HISTORY VERY CAREFULLY STARTING FROM 5 JAN 2015. - CHEMOTHERAPY SERVICE FEE NOT PAID FOR EACH WEEK OF CHEMOTHERAPY RECEIVED STARTING 5 JAN 2015 BUT SUPPORTING DRUGS, MATERIALS & FLUIDS WERE PAID AS PER AUTHORISATION ********** 9.</p> <p>Although membership was changed in 2015, some items from authorisation no. ********** 9 were still being paid for each week of chemotherapy. Refer to claim transaction history for Dr. Pirjol and refer to the treatment plan for 2014. You will clearly see that 'Supporting drugs, materials, fluids' were being paid for each week of chemotherapy from 5 Jan 2015 using authorisation number ********** 9. but for some reason discovery decided not to pay the Chemotherapy service fee charged for from 5 jan 2015 although it appears on authorsation ********** 9. The explanation is the benefits were not loaded in jan 2015 and was backdated in mar 2015. The error was only acknowledged in Mar 2015. How then did discovery pay the 'Supporting drugs, materials and fluids' for each week of chemotherapy COMMENCING 5 JAN 2015 as discovery claims that the benefits were not loaded??? How can discovery choose to pay some items to Dr. Pirjol from the initial authorisation ********** 9 and other items be rejected on the grounds that the benefits were not loaded ?? Clearly someone there did not know what they were doing. I need a detailed explanation as to why and how selective payment was done. <br />Due to selective payment from the initial authorisation ********** 9, the 'chemotherapy fee' was not being paid, discovery says that it was pushed into the self payment gap. This was not supposed to happen as members are flagged for chronic illnesses and also selective payment was being done which makes no sense. You cannot now say that benefits were not loaded as payment was done for other items since jan 2015. CAREFULLY CHECK TRANSACTION HISTORY, TREATMENT PLAN AND DISCOVERY APPROVAL ********** 9. how and why is the member responsible for discoverys errors ??</p> <p> </p> <p> </p> <p>REFER TO TRANSACTION HISTORY FOR CLAIM OF R191.20 TO DR. PIRJOL ON 30 JAN 2015 - THIS CLAIM HAS NOTHING TO DO WITH ANY TREATMENT PLAN BUT HAS EVERYTHING TO DO WITH IN HOSPITAL BENEFIT WHICH DISCOVERY FAILED TO PROCESS CORRECTLY.</p> <p><br />Mum was admitted to hospital 28 Jan 2015 - 30 Jan 2015. Dr. Pirjol had billed for consultation for 28 jan - 30 jan. Payment for consult was paid for 28 and 29 Jan 2015 but consult for mums last day in hospital on 30 Jan was not paid for. Reason given is 275. This was an in hospital benefit and was supposed to have been paid for as in hospital benefit but it was not paid at the time. A reversal was done for this consult of R335 on 17 June 2015, Reason 36 which is an adjustment of a claim. However R191.20 was finally paid to Dr. Pirjol 24 June 2015. Doctors consult is supposed to be paid up to discovery health rate for in hospital benefits. Discovery erred again by processing incorrectly and sending to the spg. It has nothing to do with oncology treatment plan as it is an in hospital benefit. How and why is the member held responsible for discoverys errors ??</p> <p> </p> <p> </p> <p><br />REFER TO CLAIM OF R152.50 (R125.80 & R26.70) FOR DU BUISSON AND KRAMER ON 30 JAN 2015. CAREFULLY READ TRANSACTION HISTORY FOR DU BUISSON. THIS CLAIM HAS NOTHING TO DO WITH ANY TREATMENT PLAN BUT HAS EVERYTHING TO DO WITH IN HOSPITAL BENEFIT WHICH DISCOVERY FAILED TO PROCESS CORRECTLY.</p> <p><br />Again mum was admitted to hospital from 28 jan 2015 - 30 jan 2015. These two amounts were supposed to be paid from the in hospital benefit which was not done, Reason 275. Again it was incorrectly processed by discovery and reversed pushing it into the spg. So many reversals were done and then reprocessed, clearly shows someone did not know what they were doing. It has nothing to do with oncology treatment plan as it is an in hospital benefit. How and why is the member held responsible for discoverys errors ??</p> <p> </p> <p> </p> <p> </p> <p><br />REFER TO CLAIM OF R288.80 FOR QESTMED PHARMACY. CAREFULLY READ TRANSACTION HISTORY FOR QESTMED PHARMACY. PAYMENT IN JAN 2015 WAS MADE USING TREATMENT PLAN, AUTHORISATION ********** 9</p> <p><br />Im told that Qestmed will not release the drugs until payment is received. Qestmed pharmacy was paid for claims from 19 jan 2015 using initial Authorisation ********** 9. Again why was Qestmed paid using the initial authorisation ********** 9 and Dr. Pirjols chemotherapy service fee of R8242.50 was rejected?? The amount of R288.80 is a result of of two claims processed as one, the amount being R509.76. It was processed and rejected on 23 jan 2015, reason 275. then it was reversed on 29 jan 2015. Then R509.76 was processed and reversed on 7 feb 2015. Then once again processed and reversed on 16 feb 2015, this happens about 3 times on the process date of 16 feb 2015. Look on page 5 of transaction history treatment date 26 jan 2015 and processed 16 feb 2015. R509.76 was processed and apayment of R220.96 was made an it states that R288.80 was for the member to pay. After that theres more processing and reversals. Really discovery what happened here? The final reversal of R288.80 was pushed to spg. Yet again discovery again. How & why is the member held responsible for discoverys errors ?? </p> <p> </p> <p>I need detailed explanation to all of the above errors as well as a valid reason as to why the member is liable for discovery's self incurred debt. Also email the day to day expenses you mentioned before R58 802.68. Please do not give me the same explanation you gave me, i want detailed answers. Yes i will be lodging a complaint to the Council.</p> <p>Please do not call me with a reply, Kindly email me your reply with detailed explanations for all your errors.</p> <p> </p> <p><br />Thank you</p> <p>Z. Allim</p> <p> </p> <p> </p> <p> </p>