Discovery Does Not Cover Prescribed Minimum Benefits

<p>I recently had a fall which resulted in a broken wrist (17th April 2016) and had to be rushed to the emergency rooms at Busamed hospital (Discovery aligned). X-rays were done & I was administered pain medication - the doctor on call, an orthopaedic surgeon, visited me in the ward the following day explaining that there was severe swelling due to the severity of the break & that he could not proceed with the operation until it subsided. He then discharged me from the hospital with my surgery being scheduled for 4 days later.</p> <p>Shortly after I was discharged, I received a call from a Discovery employee, who proceeded to read out the prescribed minimum benefit act and in short - stated that the procedure was covered under the prescribed minimum benefit, up to the agreed upon amount (One wonders if Discovery considers it ethical to be reading out an act and throwing out terms and conditions of payment to a patient in extreme pain and on schedule 5 medication). What's also astounding is that, the Discover employee informed me that despite my case being covered under the prescribed minimum benefit rule, I would still be liable for the doctors bill even if I remained in the hospital up until the procedure. This statement is in stark contrast to what the prescribed minimum benefit act outlines. This conversation left me very confused as to whether or not my procedure was covered. </p> <p>The surgery was performed on 21st April and I was discharged the next day, after which I learned that Discovery only covered about 30% of the surgeon and anaesthetist bills. After inquiring with Discovery regarding them not paying, I received two different responses in what seemed to be a tactic to evade payment...</p> <p>On the 28th of April- Discovery stated that the doctor hadn't specified that this was an emergency procedure when processing the claim. I was then told to send a motivation letter from the doctor (is this the patients responsibility?) stating that this was an emergency procedure and should be fully paid according to the prescribed minimum benefit rule, for the claim to be processed. I followed the instruction and the letter was submitted.</p> <p>On the 2nd of June- after receiving the letter from the surgeon Discovery changed their tune and said that the procedure was in fact an elective one as I was discharged from the initial admission on the 17th April and re-admitted on 21st April when surgery was performed. To add weight to their claim, they are stating that I app**** for authorisation before the surgery, was told the doctor was not on the Discovery network and that I had enough time to find a different doctor that was part of their group. </p> <p>I then escalated my query to Milton Streak, a principal officer via email who tasked their Executive Relationship Manager Keymira Sigamoney, to investigate. Apparently my claim was escalated to the highest authorities in Discovery. According to Keymira, the outcome of this review was that their previous stance still holds. It's funny how I was not included in this review process but was merely given feedback. This is the best part, Keymira informs me that my broken wrist was not really an emergency as I was well enough to call them and investigate the payment details before the procedure. She further went on to inform me that I am welcome to take this matter to the Ombudsman. </p> <p>I then took it upon myself to investigate the prescribed minimum benefit act in order to validate if what Discovery claimed about my broken wrist not being an emergency was in fact true. It then became clear from the act that a broken wrist is listed as one of the prescribed minimum benefit conditions that are, by law, required to be fully covered by any medical aid. </p> <p>When a person is admitted for an emergency they generally do not have the luxury to pick and choose doctors and their supporting staff (anesthetist)- the hospital allocates these. If the hospital is Discovery aligned (like this case), and they capture your medical aid details before you are admitted, perhaps Discovery should be asking why their partner hospitals are allocating non Discovery doctors to patients on the Discovery medical aid? </p> <p>How does Discovery expect a patient suffering from a medical emergency as classified under the PMB act, to go out and find a surgeon and anaesthetist who are on the Discovery network before a procedure is done? If Discovery really does feel that I had enough time to find alternate medical providers they should have phoned me and been explicitly clear about this - how can a medical aid state that the injury is covered under PMB & then in the same breath state that the doctor is not covered?</p> <p>Would Discovery have done this to Adrian Gore or any of his loved ones? I suppose that when you are raking in millions from poor hard working South Africans, you can afford to blatantly refer your customers to the Ombudsman when a dispute arises.</p> <p>Seemingly, you fork out your monthly payment yet you are NOT covered for any emergencies. Discovery 'plan details' have been cleverly written, with hidden terms and conditions one learns at a great cost allowing Discovery to be untouchable. Based on how I have been treated, it is worrying for how Discovery would treat the average South African with little knowledge of the law and recourse for such action...</p>