Discovery Health: ********* *******

My wife was booked in this past Monday as an emergency patient in a Netcare hospital and was later admitted to a ward due to the seriousness of her condition. This hospital is part of our Delta network and should be fully covered for in hospital treatments.

A specialist maxillofacial surgeon had to attend to her as her condition required his professional assessment. On assessment he discovered that she has developed a very big cyst above her upper jaw molar tooth and it was pushing into her sinuses therefore causing a major infection spike in her body which was affecting her to an extent where she could not eat or talk and was in a lot of pain.

The hospital then booked her in and started IV treatments of antibiotics and also glucose to stabilise her as her blood sugar was on 2.5 and she was in critical condition.

The surgeon instructed he would have to operate on her cyst in theatre as this is a critical and intricate operation to be performed. In doing so he would have to extract her tooth to access the infected area and do a host of surgery to remove and restore the jaw area.

The surgeon offices provided us a quote which had to be paid upfront and then we claim from our Discovery medical plan. I called the Discovery call centre and provided them all the details inclusive of ICD10 codes for preauth of this surgery which is taking place as I am typing this message.

Discovery call center had determined that quotation provided by the surgeon will not be paid back to us in full as this surgery is not deemed serious and they look at this procedure as a dental procedure instead of an operation to access the cyst. They are only able to pay less than 50% of the entire claim because their call centre has the ability to make these decisions without requesting any reports or scan data or proper evidence from the doctor or the hospital.

This is clear daylight ******* and ********* business behaviour from Discovery Health. Please beware that should you go for a procedure and have your health plan with Discovery Health that you most likely will not be paid back what is due to you. What is the purpose of having a medical health plan if they cannot cover your expenses in your time of need? They are a total ******* and are ********* in any way possible as I am sure this is their business model on how to rip their clients off. I am going to pursue this matter further with whichever medical board to adjudicate this matter as Discovery health are bullies and think they can just dicatate to us as their clients as they please and we must just accept whatever they throw at us.