1 reviews | Active since Dec 2010
Discovery Health - Social Club instead of Med Aid
To Whom it May Concern,<br> <br> I am yet again appalled at Discovery Health and the manner in with they handle large claims with every excuse under the sun so as not to settle them. It's clearly visible that they focus more on being a social club (Vitality, etc.) instead of focusing on the essence of being a true medical aid service provider.<br> <br> On 25/08 I went in for a Level 3 gestational scan which lead to an amnio.<br> <br> I had a Self Payment Gap of R3177.37 to cover hence settled the gynae bill of R3600 & sent them the claim on 27th August. This service provider charges out of medical aid rates.<br> <br> The pathologist account amounting to R4046.20 was submitted to Discovery on 28/08 - a day after I submitted my claim. They charge medical aid rates.<br> <br> The pathologist account was settled from my Self Payment Gap and the Gynae bill which was submitted first was settled out of my Threshold leaving me with a high portion to pay out of my pocket. Long story short, out of a R7646.20 claim, Discovery only settled R2173.55. What's the point of paying so much for a medical aid each month in ZA if they hardly there for you when you really need them?
Thank you for your comment.
The Self-Payment-Gap (SPG) is active when you have used all the funds in your Medical Savings Account (MSA) before your expenses are equal to the Annual Threshold. During this time, you will need to pay for day-to-day expenses from your own pocket. These claims must be sent to the Scheme as they will accumulate towards the Annual Threshold up to the Discovery Health Rate (DHR). This means that if the doctor charges R 2 000 and the Scheme rate is R 1 000, only R 1 000 will be taken into account when closing the SPG.
We confirmed that we received the gynecologist claim on 27 August 2015 and it was processed on 28 August 2015. We paid this claim from your Above Threshold Benefit (ATB) up to the Scheme rate. If we processed the claim while you were in your SPG, we would have only accumulated the Scheme rate to close the SPG. The total amount paid from your ATB would not have changed regardless of which claim was processed first based on the fact that the claims only accumulate at the Discovery Health Rate and not the private rates.
We're sorry that we could not provide you with a more positive outcome.
Regards
Annelize
Thank you for your comment.
The Self-Payment-Gap (SPG) is active when you have used all the funds in your Medical Savings Account (MSA) before your expenses are equal to the Annual Threshold. During this time, you will need to pay for day-to-day expenses from your own pocket. These claims must be sent to the Scheme as they will accumulate towards the Annual Threshold up to the Discovery Health Rate (DHR). This means that if the doctor charges R 2 000 and the Scheme rate is R 1 000, only R 1 000 will be taken into account when closing the SPG.
We confirmed that we received the gynecologist claim on 27 August 2015 and it was processed on 28 August 2015. We paid this claim from your Above Threshold Benefit (ATB) up to the Scheme rate. If we processed the claim while you were in your SPG, we would have only accumulated the Scheme rate to close the SPG. The total amount paid from your ATB would not have changed regardless of which claim was processed first based on the fact that the claims only accumulate at the Discovery Health Rate and not the private rates.
We're sorry that we could not provide you with a more positive outcome.
Regards
Annelize