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Lize M

1 reviews | Active since Nov 2018

13 Aug 2025, 12:01

Emergency Room Visit – Unreasonable and Unclear Claim Process

I recently had to visit a hospital emergency room for severe and persistent vomiting with intense stomach and back pain. Although my policy does not cover that hospital, the policy wording explicitly states that this restriction “does not apply in an emergency,” and that in such situations, members are entitled to seek care at any hospital.

However, I was informed after the fact that my visit would only be reimbursed if I personally obtained a completed “Prescribed Minimum Benefit” (PMB) form from the treating doctor and attached all relevant reports — despite this being one of the scheme’s own network hospitals. This process is highly impractical, especially when treatment occurs in the early hours of the morning or far from home.

My frustration is not with the advisor who assisted me — they were polite, empathetic, and patient. Rather, it is with the medical aid’s process and definition of emergencies:

The Medical Schemes Act clearly states that emergencies must be assessed on a case-by-case basis using a broad legal definition. Yet in practice, the scheme appears to rely on a fixed list of “approved” diagnosis codes.

Although I was told my claim could be “reviewed” after completing this tedious submission process, I was also informed that, because my diagnosis code is not on the pre-approved PMB list, the claim will almost certainly be declined.

This approach places the entire administrative burden on the member rather than utilizing information the scheme should already have access to. Despite the policy wording stating that restrictions do not apply in an emergency, cover is not automatic, and upfront payment is still required unless the claim passes this extra review.

This process is unnecessarily burdensome, discourages legitimate claims, and is inconsistent with the Treating Customers Fairly (TCF) principle. In a genuine emergency, the priority should be receiving urgent care, not chasing doctors and paperwork days later, knowing that the claim may likely be denied due to a technicality.

I request that the medical aid review both their definition of emergencies and the process for handling emergency claims so that members receive fair, practical, and consistent treatment in urgent situations, regardless of whether the hospital is within the network.

0
Replies (9)
Discovery Health
Discovery Health's reply13 Aug 2025, 12:18
Official
Dear Lize M

We’ve noted your concerns and we’re investigating the matter. We’ll contact you with feedback as soon as possible. 

Regards 
Discovery Health Servicing Team
LM
Lize M's update15 Aug 2025, 07:02
Reviewer Update
I received a response from the scheme advising that “treatment received in a casualty unit is regarded as an out-of-hospital medical expense and is covered from your Medical Savings Account, subject to funds being available.” This was the entirety of the explanation, aside from noting that they had tried to call me.
Unfortunately, this does not address the substance of my original complaint.
My concern was never simply about whether casualty unit costs are normally paid from the Medical Savings Account — it was about the fact that your own policy wording states that the hospital network restriction “does not apply in an emergency,” and that in such cases members may seek treatment at any hospital.
I specifically queried:
  1. The definition of an “emergency”
    • The Medical Schemes Act requires a broad, case-by-case assessment. My symptoms — severe and persistent vomiting, intense stomach and back pain — were sudden, serious, and warranted urgent care.
    • Your process appears to apply a rigid list of “pre-approved” PMB diagnosis codes instead of assessing each case individually, which is inconsistent with the Act and with Treating Customers Fairly (TCF) principles.
  2. The impractical and burdensome PMB claim process
    • Requiring members, after the fact, to personally obtain forms and reports from treating doctors is not reasonable in a genuine emergency.
    • This shifts the entire administrative burden onto the patient, even when the scheme already has access to most of this information.
  3. Contradiction between policy wording and practice
    • Your policy states network restrictions do not apply in an emergency, yet in practice cover is not automatic, and members are still required to pay upfront unless the claim passes an extra review.
The response I received simply restated the default rule for casualty claims without engaging with these specific points or explaining why the emergency provision in your own policy did not apply in my case. I again request that you:
  • Provide a clear explanation of how “emergency” is determined in line with the Medical Schemes Act.
  • Explain why my case did not qualify as an emergency despite the symptoms described.
  • Review the practicality and fairness of your current PMB submission process in genuine emergencies.
I would appreciate a detailed, answer rather than a generic restatement of benefits.
Discovery Health
Discovery Health's reply15 Aug 2025, 14:16
Official
Dear Lize M

Please check your emails for final feedback from us.

Regards

Discovery Health Servicing Team

LM
Lize M's update15 Aug 2025, 14:45
Reviewer Update
Thank you for the further reply, but unfortunately Discovery has still not addressed the substance of my original complaint.
The Medical Schemes Act’s definition of an “emergency medical condition” is broad and must be app**** case-by-case:
“…the sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment of bodily functions or organs, or would place the person’s life in serious jeopardy.”
The Act does not say that only certain pre-approved diagnosis codes qualify as emergencies. Yet Discovery’s process treats “emergency” as a fixed list of codes — a practice I have already been told will cause my claim to be declined. This is inconsistent with both the law and Treating Customers Fairly (TCF) principles. My policy wording clearly states:
“Network restrictions do not apply in an emergency.”
However, in practice:
  • Upfront payment is still required.
  • Cover is only considered if the member, after the fact, personally obtains a Prescribed Minimum Benefit form, provider motivation, diagnostic codes, and incident reports.
  • This process shifts the full administrative burden onto the patient, even though Discovery already has access to much of this information.
This is not a reasonable or fair process in a genuine emergency, especially when treatment occurs far from home or in the early hours of the morning. The “final feedback” wording in your last message also suggests an unwillingness to answer my specific questions, namely:
  1. Why was my case not deemed an emergency despite meeting the Act’s definition?
  2. How does the policy’s emergency clause apply if not in situations like mine?
  3. Why does Discovery rely on a fixed list of diagnosis codes when the law requires a broader, case-by-case assessment?
Until these points are addressed directly, the core of my complaint remains unresolved.
Discovery Health
Discovery Health's reply21 Aug 2025, 08:11
Official
Dear Lize M

Please check your emails for final feedback from us.

Regards

Discovery Health Servicing Team

LM
Lize M's update21 Aug 2025, 09:20
Reviewer Update
Thank you for your reply, but once again, the response avoids the core issue I have raised.
You confirm that claims are processed based purely on procedure and diagnostic codes submitted by the provider, and that unless I go through the burdensome PMB process myself (obtaining forms, reports and motivation), the claim will remain unpaid. This illustrates exactly the problem:
  1. Rigid code-based approach
    The Medical Schemes Act requires a broad, case-by-case definition of “emergency medical condition.” Nowhere does the Act state that only certain diagnosis codes qualify. Yet Discovery relies solely on codes and pre-approval lists, ignoring the Act’s definition.
  2. Administrative burden shifted to members
    In genuine emergencies, it is not reasonable or practical to expect members to chase doctors for forms and incident reports after the fact. Discovery already has access to hospital records and diagnostic codes, but still requires members to do additional paperwork before even considering a review.
  3. Contradiction with policy wording
    My policy wording states clearly that “network restrictions do not apply in an emergency.” In practice, however, upfront payment is still required and cover is only considered after an additional review process which Discovery has already indicated will almost certainly be declined. This is inconsistent with both your own wording and with Treating Customers Fairly (TCF) principles.
  4. Narrow interpretation of emergencies
    Your latest reply suggests that unless an admission is required, it is not regarded as a “really severe” condition and therefore not an emergency. This is directly at odds with the legal definition, which covers sudden and unexpected health conditions where failure to treat could jeopardise life or bodily function — not only cases that result in admission.
What I am asking for is simple:
  • A clear explanation of how Discovery applies the Act’s definition of “emergency” in practice.
  • Clarification of why my symptoms (sudden, severe vomiting with intense pain) do not qualify under the Act’s definition.
  • Confirmation of why the burden of proving an emergency is placed entirely on the member, instead of Discovery proactively reviewing available records.
So far, every response has restated scheme rules without addressing these specific questions. Until they are answered, my complaint remains unresolved.
Discovery Health
Discovery Health's reply28 Aug 2025, 08:16
Official
Dear Lize M

Please check your emails for final feedback from us.

Regards

Discovery Health Servicing Team

LM
Lize M's update28 Aug 2025, 14:09
Reviewer Update
Thank you for the latest reply. Unfortunately, Discovery continues to avoid answering the specific questions I raised and is instead shifting the entire responsibility for proving an emergency onto me as the member.
Your response confirms the following:
  • Discovery relies on limited claim codes to reject casualty claims, even where the Medical Schemes Act requires a broader case-by-case definition of “emergency.”
  • Instead of requesting information directly from providers (whose details have access to), the member must personally chase incident reports, pathology, radiology, and PMB forms after the fact — in other words, the administrative burden rests entirely on the patient.
  • Even if all this documentation is submitted, you admit that payment is not guaranteed, which makes the process unnecessarily uncertain and discourages valid claims.
  • The contradiction between your policy wording (“network restrictions do not apply in an emergency”) and your practice (requiring upfront payment and lengthy post-event admin before even considering cover) remains unaddressed.
My complaint has always been about principle and process, not just about this one claim. In a genuine emergency, patients need urgent care — not a mountain of paperwork afterwards and the risk of their claim being declined because of “scheme rules.” This is inconsistent with the Medical Schemes Act and Treating Customers Fairly (TCF) principles. Since Discovery has not provided direct answers to the specific questions I raised, and now refers me only to the Disputes Committee, I will be escalating this further.
Discovery Health
Discovery Health's reply03 Sept 2025, 13:39
Official
Dear Lize M

We have been in touch with you to answer your comments.

Regards

Discovery Health Servicing Team