Failure to cover medical cost

Be very careful when you decide on which medical scheme to choose, especially if you are young and plan to have a family in the near future. I will try to explain my statement by describing the recent sobering experience I had with my medical aid. Our family of three, two adults and one child, has been members of Discovery Medical Aid under the Classic Priority Plan since 2010. Other than the occasional visit to the GP, I regard us as a generally healthy family and therefore do not incur large medical expenses, until recently. Actually, if measured against my financial contributions towards the fund over the past ±8 years, my claims have been marginal My son was born with a condition that is called Pectus Excavatum. This condition is also known as sunken or funnel chest. It is a con******* chest wall deformity in which several ribs and the sternum grow abnormally, producing a concave, or caved-in, appearance in the anterior chest wall. This was noticeable shortly after his birth but it worsened significantly during his growth spurt over the past ±3 years. He eventually asked me if we can consult a doctor as this was becoming a worry to him. The Cardio Thoracic Surgeon that we visited classified it as a severe case of Pectus Excavatum. He (my son) then decided that he would like to have corrective surgery to repair the deformity. We immediately app**** to Discovery for authorisation. This was declined on the basis that the "benefit entry criteria was not met". The recovery time after this operation that was suggested by the surgeon is 12 months. I therefore decided that the process cannot be delayed as he will be in his final school year in 2019. On the day of admission into hospital (29 March 2018) I had to pay a deposit in excess of R100,000. Still to follow was the cost of the surgeon, anethetist, blood tests and x-rays. In order to cover all this I therefore had to incur debt, believing all the time that my medical aid will eventually assist Before and after the operation I communicated with Discovery, trying to understand why they declined. Out of frustration due to a lack of proper explanation on the decline, I approached the Council for Medical Schemes on 20 April 2018. Eventually, after numerous emails and phone calls to the Council, I received feedback from them on 06 July 2018. A letter send to them by Discovery, confirming that my application is declined. During my communication with Discovery before the operation, it was indicated that if I upgrade to a higher plan, they will review the application. When I signed up under this medical plan, I was under the impression that my family and I will be covered, if not in full then at least partially, when medical treatment is required. The only logical explanation that I can make from all this, is that Discovery does not view a severe Pectus Excavatum to have any negative medical issues The following is a case of Pectus Excavatum that I came across: "A healthy 59-year-old male patient complained of progressive heart palpitations, fatigue and postural dyspnoea; bending over caused a clear increase of dyspnoea. At repeated examinations no overt abnormality or explanation was found, except a supraventricular arrhythmia and a nodal tachycardia. In the years to follow the symptoms led to considerable physical impairments. Finally, the patient himself, after searching the web, came up with a possible cause: his pectus excavatum. A lateral chest x-ray with the patient bending over and a lateral computed tomography of the thorax revealed an impression of the heart by the sternum. Ten years after the patient’s signs and symptoms first appeared, a modified Ravitch procedure was carried out, after which the physical condition of the patient improved rapidly." Discovery requested certain tests to be done on which they based their decision. These included ECG and/or cardiac echo report and lung function test. I am however not convinced that these tests are sufficient to determine the full impact as my son often complained that he struggle to take a "full breath intake "when jogging. He also complained of discomfort when doing certain exercises in the gym. Perhaps the tests requested should be done when placing the body under some strain in order to be certain that the deformity has absolutely no impact on the wellbeing of the patient My advise is therefore to young people to make very sure on what is not covered by the medical scheme you are considering before making a final decision, especially if there is children in the planning. Surely I can be excused for having a completely different view on why Discovery was able to declare such huge profits during the past financial year, than the reasons recently offered in the media