Discovery Health complaint

Hi there,

Where do I start? As usual the consumer must just pay. The detail below is what sent to the council for medical schemes at the beginning of the month and am still waiting for a response.

Clearly, in most of our industries, the consumer is taken for a ride regardless of the poor systems & service.

I would like to make a complaint against my medical aid, Discovery. I have been with them for many years. There are numerous issues for me. For the last few years we have been on the Coastal Core plan. At the end of last year, in consultation with our Discovery advisor, we decided to change to the Classic Smart plan. To summarize, we were informed that this is a better plan with a small increase in premium. Since our first doctor’s consultation we have been confused with this plan – what the medical aid pays for and what we must pay for. Where we stand now, we must pay for services rendered which we feel is not our responsibility. Firstly, my wife and I decided that I should go for a vasectomy as we were not planning on having any more children. After, identifying a specialist in the area able to perform this procedure, I was informed that I needed to go for a consultation first before having the procedure. Discovery does not pay for this, but yet they pay for the procedure. I had the procedure in July. The operating doctor said that I must go for a ***** test in 3 months’ time. Discovery does not pay for this either. I still don’t know if the procedure was successful as I have not gone for this analysis. How is it possible that I have the option of having a family planning procedure paid for, yet still need to pay for other services that are required to do this procedure? My wife went for a Papsmear in September through the correct plan doctors. The doctor suggested checking for the papilloma virus due to her age. We understand this virus to be linked to cancer somehow. Sorry, I am not a doctor. We received an account from Pathcare showing that this test is not paid for by our medical aid. So this shows us that Discovery’s screening and preventative benefits are only there to encourage a person to join their scheme, and not actually help identify concerns in a patient early. Please also see motivational letter attached from Dr van Zyl. My wife also went for a Mammogram in October, which Discovery has paid for. Unfortunately, the tests indicated a lump on one of her breasts. One of the doctors at this facility checked her and said she was going to send the results on to Dr van Zyl. After Dr van Zyl reviewed the results, her secretary made an appointment for my wife to see a breast specialist. The secretary phoned my wife and my wife said she would like a quote first. The secretary gave my wife the number and she phoned. My wife phoned the beast specialist office and was given a quote. My wife then went for the examination at the breast specialist. After the examination, the breast specialist sent the account to Discovery. After a few days, we were informed that Discovery did not pay this account. I then had a meeting with my Discovery advisor and he phoned his secretary to investigate the non-payments of my wife’s examinations. The first time his secretary phoned my wife, while the advisor and I were still having the meeting, she was misinformed that the lump was cancerous and asked my wife to get a referral letter. The advisor’s secretary then phoned a second time to say it is not necessary for a referral letter anymore because the lump is not cancerous and Discovery is not going to pay. Discovery only pays if it is cancerous. The advisor’s secretary also mentioned that I should not have changed our plan. Discovery would have paid for the specialist. My wife also informed her that the specialist is not worried at this stage, but also cannot determine the cause of the lump and that she should come back in 6 months. The advisor’s secretary said that Discovery will pay being a new year. What is disturbing us is that we have these Screening and Preventative Benefits that we pay for, but Discovery will only pay when they want to. Firstly, may you please explain how this “paid for” vasectomy works? This specialist requires a consultation before doing the operation, which Discovery does not pay for. Then after the 3 months I must go for a test to confirm that the doctor operated correctly, which is also not paid by Discovery. Secondly, Discovery does not want to pay for a test that identifies cancer according to SASOG guidelines for a patient over 30 yrs old, mentioned in Dr van Zyl’s motivational letter. This then tells me that Discovery is deceiving its clients as the test they pay for is actually meaningless in this case and is unable to identify what it needs to! How many other clients are being deceived? Thirdly, the Mammogram means nothing without the specialist. The Mammogram is just a specific test that gives information – in this case a lump on a breast. A specialist doctor is still needed! Even after a consultation with a specialist, which was recommended, we have no definitive information. So now depending on whether there is definitive proof and if it is cancerous, only then will Discovery pay! We are very unhappy about the service we are getting from Discovery and we think people need to be made aware of this. To us, this is ********* practice which needs to be revealed. What is also disturbing is that even the doctor’s opinion is being ignored. May you please investigate our concerns?

Regards Keegan Thomas ***