EX GRATIA CLAIM BATTLE/ERRORS IN PROCESSING/PATHETIC SERVICE

<p>19th July 2016</p> <p>(Refer original letter sent)</p> <p> </p> <p>Dear Sir/Madam</p> <p> </p> <p>Discovery Health (Pty) Ltd</p> <p>Ex Gratia Approved Claims Department</p> <p> </p> <p>RE: MEMBERSHIP NO.: ********** 20</p> <p>CLAIM RELATING TO TREATMENT OF HEPATITIS C BEING HEPSINAT AND COPEGUS</p> <p> </p> <p>I refer to your e-mail dated the 18th July 2016 approving refund of Hepsinat amounting to R13 402-20.</p> <p> </p> <p>Please find on this letter subject line, membership number as you have requested in order to refund the claim as an ex gratia manual settlement.</p> <p> </p> <p>As previously advised to many call centre agents and managers of the various departments in addition to the many e-mails sent to the various departments of which I have correspondence in my records, this account must be settled in full as per all the invoices previously sent and not only the amount of R13 402-20 as approved. Reason for this complete refund of R37 211.37, made of up invoices for Copegus = R8 248.16 and Hepsinat = R28 963.21, is detailed as below:</p> <p> </p> <p>Towards the latter part of 2015, the patient was diagnosed with Hepatitis C and at that time was a dependent on membership no. ********** 01. The patient was treated by Doctor and was admitted for a liver biopsy procedure of which it was detected that the patient had early signs of liver cirrhosis.</p> <p> </p> <p>Doctor had submitted an application on membership ********** 01 for treatment to be paid by Discovery Health, of which this was declined by Discovery Health. On our request, Doctor then sent through a motivation for the treatment to be covered by Discovery, again on membership ********** 01 and this was still declined for both medication types. The reason for the Hepatitis C medications being declined was due to plan type and Discovery then advised in writing of which plan types would cover treatment for Hepatitis C.</p> <p> </p> <p>Due to the patient developing liver cirrhosis, the patient and his wife took a decision to purchase both medications cash to avoid the patient’s condition from deteriorating any further. The doctor agreed as he advised approval would be required from the Medicine Control Council which he arranged, the patient’s wife paid a fee to the Council for this. Medications were then ordered from both pharmacies via prescription from Doctor, the patient’s wife paid cash for every batch of medication ordered on a monthly basis, proof of these invoices have been previously submitted to Discovery.</p> <p> </p> <p>The first batch of medication was ordered in November 2015, taken to Doctor’s rooms which he approved and advised that the patient to start treatment on the 01st December 2015 so this can be monitored. In addition, he provided blood test scripts which were to be performed on certain dates as he had prescribed.</p> <p> </p> <p>The patient commenced taking both tablets on a daily basis from the the 01st December 2015, the Hepsinat was taken 1 tablet a day which he took at night, the Copegus was taken 5 tablets in the morning and 5 tablets in the evening.</p> <p> </p> <p>Due to closure of the pharmacies over the festive season being December 2015/early January 2016, the patient’s wife after speaking to the pharmacist then placed and order in December 2015 to run through end December 2016/early January 2016, only reason this order was placed in December 2015 and not in January is that the Hepsinat contains 28 tablets in a bottle and the Copegus contains 42, so both these would have run out towards the end of December 2015/early January 2016. For this reason, I requested that Discovery pay for the complete treatment which is from November 2015 to March 2016 as this the period the patient was on treatment and stopped treatment in March 2016.</p> <p> </p> <p>The patient in the interim visited Doctor in order to monitor the Hepatitis virus as well as performed blood tests per the dates required. The patient’s wife advised Doctor that the patient will be moving to a higher medical aid plan with Discovery in order for Discovery to fund the treatment. The patient and his wife asked Doctor to re-submit the application made to Discovery on the new medical plan being membership ********** 20 which he agreed to do.</p> <p> </p> <p>Follow ups’ were done repeatedly by the patient’s wife with Doctor’s receptionists to ensure Doctor submits the forms to medical aid, the patient’s wife had to plead to have this done as Doctor takes an extremely long time to submit an application, this was the same delay experienced in 2015 with the first application made.</p> <p> </p> <p>Application eventually was re-submitted by Doctor’s rooms to Discovery, Discovery received the application however did not work with it at the very onset. The patient’s wife followed up on the application with the lady at Doctor’s rooms repeatedly, who called Discovery once to twice a week to track the status. Although timelines were provided by Discovery to the lady, none were met as no progress was made with the application and she was repeatedly advised that this was still with the review team for processing.</p> <p> </p> <p>The patient’s wife herself had called Discovery and was advised the application is still being reviewed. The patient’s wife in addition advised that there was nothing difficult about the application submitted as it was already dealt with on a different membership number on two previous occasions and all that had to be done was for Discovery to re-assess the application on a new plan which Discovery did advise in writing that this will be covered if plan type changed.</p> <p> </p> <p>Following repeated calls made and e-mails sent by the patient’s wife, the patient’s wife then made a noise about the delay experienced and only to be advised that the application was sitting with Discovery and not worked on for no reason what so ever, in addition no feedback at all relating to the claim was sent by Discovery advising on the progress nor any further information that may be required in order for the application to follow process. The patient’s wife was furious and requested that Discovery immediately escalate for finalisation of the application. Had it been left to Discovery, the patient would have had fully blown liver cirrhosis by the time it takes Discovery to finalise an application – what then is the point of being on medical aid?</p> <p> </p> <p>Even with the patient’s wife putting pressure by calling almost every day to Discovery, she was then advised that the application date signed by the Doctor was incorrect and a new application must be submitted, never mind that this is now a good few months after the application was received and someone at Discovery did not do their work in the first place. The patient’s wife refused to submit a new application for two simple reasons – firstly that Discovery did not advise on receiving the application that this was a problem and had not provided no feedback whatsoever, instead they sat with the application until I complained, secondly, the Doctor does not act immediately and takes extremely long to submit an application. It was no fault of ours, and the patient’s wife then advised the manager at Discovery that this must be resolved between the Doctor and Discovery. Surely Discovery could stop being difficult and if records were pulled would have noticed that the patient was treated in 2015 and not in 2011 as Discovery claimed that the Doctor dated the application in 2011 – never mind the fact that Doctors have scribble sort of hand writing.</p> <p> </p> <p>Still, the argument continued with Discovery on having the claim finalised and many reasons were provided by Discovery in the meantime, it is with certain department, it is being worked on, it is awaiting payment amount, awaiting authorisation, require invoices which were sent, require nappy codes, etc. what is of concern is that to the patient and his wife, this is a medical matter pending since mid-2015 and still battling with Discovery to date. As I stated, had I not resorted to deciding to pay cash for the medication and waited on Discovery to finalise, the patient would by now require a liver transplant, who would then pay for this cost and who would bear the consequence of failing to resolve the application?</p> <p> </p> <p>After such a timeous struggle, the claim has now been authorised as ex gratia, however again Discovery messed up by authorising only two invoices for 2016, which they got the amount on one invoice wrong. Again I had to wait three weeks for the lady at Ex Gratia to revert on this, by sending mail after mail, and phoning in leaving messages for her. I must state that to date she has not called me. I did then receive the rectified e-mail advising that the ex gratia amount has been corrected, however this still makes up only two invoices for one type of the tablet in 2016.</p> <p> </p> <p>For the last time I urge you, and based on all the above I have stated, that the complete refund of R37 211.37 must be settled as medications were bought earlier due to closure of companies, secondly through the fault of the Doctor and Discovery and not through any fault of ours. In addition, how can it be that the Copegus cannot be funded and was advised this is claimed from savings when the cost of Copegus is over R2 000 per batch. Why then did Discovery not advise of this in the first place in 2015 when the plan was declined so I would not have changed the patient’s plan to a higher plan and simply paid cash for the Hepsinat and not pursued the claim through Discovery in the first place.</p> <p> </p> <p>Might I add, that following this letter, I expect the full refund being paid to me, secondly I will pursue this through social media, Noseweek, Hello Peter and the Ombudsman for medical Aid as I believe this struggle I have faced must be brought to light. Surely being a member of Discovery and other Discovery plans since 2010, this is not the treatment I deserve and nor will the R37 211.37 create a hole in Discovery’s funds. Definitely come end of the year, am contemplating moving all my medical cover and other plans I have with Discovery as it is not fair at all on an average individual to face such unnecessary stress whilst going through illness.</p> <p> </p> <p>Not sure who at Discovery will read this letter, I do hope this reaches the hands of someone who can make a difference to people requiring support from Discovery, as I have not received such support.</p> <p> </p> <p>Please urgently finalise this claim in full as I honestly do not have the time and strength to waste on Discovery any further.</p> <p> </p>