Discovery Gap Cover. Worth the money? We think not.

Discovery South Africa (Gap Cover) have refused to cover my wife's operation leaving us some R40,000 out of pocket. We’d like to share our experience of Discovery South Africa Gap Cover for any thinking about taking it out.

We took out the policy at the start of 2019. We were sent an offer letter explaining what was covered and that there was a mandatory waiting period of one year for some procedures. Here’s the relevant passage from the policy letter entitled “waiting periods explained”:

“An automatic 12 months exclusion waiting period applies for any claims directly or indirectly related to ... scopes (all minimally invasive scopes such as endoscopies, hysteroscopy, arthroscopy) ...”

We accepted that and didn’t bother putting in a claim for a colonoscopy in March, knowing based on the description that it wasn’t covered. You’ll note it explains specifically what it means by “scopes”.

In July my wife experienced pain and following an MRI they discovered a slipped disc in her neck requiring urgent spinal surgery. The doctor supp**** us with a list of procedures (called ICD10 codes) that we passed to Discovery Gap Cover and we phoned and asked them if these specific codes were covered or if they were affected by the waiting period. In two extended phone calls Discovery South Africa refused to answer the question. They said they couldn’t answer because the surgeon may do something different on the day, and the codes may change. We said we were sure that was an answer to some question, but not the one we asked. We were asking if these specific ICD10 codes were subject to a waiting period. Again and again they refused to answer. We’ve asked for copies of the recordings of these calls, but have not yet received them.

We went ahead with the surgery, and Discovery Gap Cover then used those exact same IDC10 codes to deny cover, citing a waiting period for scopes.

They made this decision since the doctor used a micro-scope during the surgery. This even though the scope was used during open surgery (she has the 10cm scar to prove it) and doesn’t in any way match the exclusion for “minimally invasive scopes” to which we had agreed on taking out the cover. Discovery won’t tell you which ICD10 codes are excluded until after the event for which you’ve paid them for cover. You have to sign the contract for the cover based on the description in the letter, not the specific ICD10 codes that are excluded. You have to take a leap of faith.

So we appealed. They denied cover again for the same reason, citing the ICD10 codes we’d provided. The same ICD10 codes they won’t tell you aren’t covered. But these secret codes don’t match the description of the cover that is supp**** when you take it out.

And they not only refused to cover the cost of the scope, but the entire operation, the consultancy fees, the MRI that was several days before the op, anything related to her condition – all because the surgeon used a scope in the subsequent operation.

Imagine you had taken out travel insurance, but in the policy there was an exclusion for certain colour suitcases. So before your trip, you phone them up to find out if your blue suitcase is excluded from cover. “Are you making a claim sir?” “No, I’m just going on a trip and want to know if my suitcase is excluded” “I’m sorry we can’t tell you if blue suitcases are excluded until you make a claim, because we don’t know if the suitcase you might claim on will be blue” “I’m not asking about some fantasy future claim. I’m asking if you exclude blue suitcases in the first year of the policy...” “I’m sorry, we won’t answer that sir” So you take your blue suitcase, because you have no idea which one they’ll exclude. You lose your suitcase. And when you put in your claim, it is denied because there is an exclusion for green suitcases. But what is more – you lost your suitcase because the plane crashed and you broke your arms and legs. And that’s not covered either, because you took a blue suitcase with you that they classed in a secret document as green. If they’d told you in advance that your blue suitcase was classed as green in their secret document and that green suitcases were excluded, you’d have taken your red suitcase just to be safe.

In the medical example, you’d have spoken to the surgeon, and said that this particular part of the procedure is not covered by my insurance, in fact it invalidates the entire claim.

“So what are my treatment options?” you’d ask. “Can we ensure that we use a treatment that is covered by my insurance policy?”. But you can't do that, because they won't tell you specifically what procedures are (not) covered by your policy until after you have them. This enables them to deny far more claims than they otherwise would. Though friends, countrymen, I’m sure that’s not their motivation, for Discovery is a company run by honorable men.

So that’s our story. We’re not making a recommendation to you on Discovery South Africa Gap Cover. Make up your own mind. This was our personal experience.