Hospital Authorisation delay tactics

On the 12th of October (Saturday) I was admitted to Mediclinic Medforum which is part of the Smart Hospital Network, on an emergency basis into the casualty unit.

Your' website states that: "If you have an emergency, you can go straight to hospital."

A hospital authorisation (2 3 4 7 4 5 3 7) was requested on that same day by the treating Dr. Elnagar A A - Gastroenterologist (0 1 9 1 7 0 1). The authorisation was not approved. One of your consultants claims that I am the one who requested the authorisation however she could not prove this.

As a result, I was requested to pay out of pocket for the emergency room bill, yet your website stipulates that:

"We cover the costs of a casualty visit if you are admitted to the hospital from the casualty unit. We pay the costs from your Hospital Benefit, as long as we confirm your admission. Some casualties charge a facility fee, which we do not cover."

Radiology and Pathology tests were performed however, I was told to pay beforehand. 'Mauff A C And Partners' attempted to claim from Discovery however this was rejected. Your website stipulates that:

"We pay your hospital account up to a maximum of the Discovery Health Rate and your related accounts up to a maximum of 200% of the Discovery Health Rate. Radiology and pathology are paid up to a maximum of the Discovery Health Rate".

The following day on Sunday I was scheduled for a colonoscopy and gastroscopy diagnosis & went through the laxative preparation, however as I was about to be put under anesthesia the procedure was stopped due to Discovery not approving the Hospital admission. Your' website stipulates that:

"If you have a scope (gastroscopy, colonoscopy, sigmoidoscopy, proctoscopy, cystoscopy) performed during your approved hospital admission, your claims will be paid based on the Discovery Health Plan you have chosen and is subject to preauthorisation and approval"

Since I am on the Smart Classic Plan it further states that: "You are responsible for paying the first R4 550 of your hospital account. The balance of the hospital account and the related accounts are paid from your Hospital Benefit "

The authorisation was requested and multiple calls were made to Discovery for both the gastroscopy & colonoscopy in-hospital diagnosis authorisation.

Discovery sent PMA forms to my GP (who is not a Gastroenterologist) to find out whether a gastroscopy & colonoscopy diagnosis was ever made. *How do you send a PMA form to a general practitioner for a gastroscopy & colonoscopy diagnosis?

Thereafter, after several hours of speaking to Discovery, a PMA form was sent to the treating Dr. Elnagar A A - Gastroenterologist (0 1 9 1 7 0 1) who is part of the Discovery Medical Scheme, however, you misspelled his name & sent the form to non-existent email. Usually, when a document is sent to a non-existent email, the email will bounce immediately, yet Discovery oddly did not take not of this.

Your site states that: "An emergency medical condition also referred to as an emergency, is the sudden and unexpected onset of a health condition that requires immediate medical and surgical treatment. Failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place the person’s life in serious jeopardy. An emergency does not necessarily require hospital admission. We may ask you or your treating provider for additional information to confirm the emergency."

Unless I am absurd I am starting to wonder whether Discovery is using the fact that I only joined the scheme in February to delay the procedure so that I can stay at Mediclinic Mediforum longer, in the end, pay all the expenses incurred out of my own pocket.

Your delay tactics are not the first. Your so-called 'standard department' is complicit in this delay tactic. I have now been in Mediclinic Medforum for five days & the financial department wants to find out how I am going to pay for all the expenses incurred.

The following are Discovery consultants I have spoken to, who did nothing but deplete my frail voce & airtime: THASVIR - Ref: ***HANDIE - Ref: ***NOLITHA - Ref: ***NANDIPA - Ref: ***SINDISIWE - Ref: ***EVELYN - Ref: ***ZANDILE - Ref: ***KHOLEKA - Ref: ***PHOLISA - Ref: *** My question is, does this so-called 'Standard Department' even exist since the blame for the delays is always shifted to them however, I have never once spoken to anyone who works there?.