PS
PragasenSoobramoney S

1 reviews | Active since Jun 2013

16 Apr 2018, 12:36

NON PAYMENT IN A CASE OF AN EMERGENCY

Dear Mr Soobramoney

Thank you for contacting us.

Feedback on claim for VD A****as

Our Clinical Department has advised us that the benefits on your plan type is richer than the benefits on the Prescribed Minimum Benefits (PMB). We were also advise us that the provider is no a Designated Service Provider.

PMB

PMB’s are a set of minimum benefits that, by law, must be provided to all medical scheme members. The cover it gives includes the diagnosis, treatment and cost of ongoing care for a list of conditions. The list of conditions is defined in the Medical Schemes Act 131 of 1998.

As per Regulation 7 of the Act, emergency medical condition is defined as - "the sudden and at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment of bodily functions or serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy".

Legislation allows medical schemes to use risk tools to ensure that funding of Prescribed Minimum Benefits remains sustainable now and in the future.

Members are entitled to full cover as long as the below three requirements are met:

Valid medical condition

The medical scheme needs to be provided with sufficient diagnostic information to identify the condition and determine if the severity qualifies for the treatment requested.

Chosen treatment is included in the defined benefits

There are standard treatments, procedures, investigations and consultations for each PMB condition. The scheme is only required to provide cover for these defined benefits (except on appeal).

Participating healthcare professional and or hospital

The medical scheme is required to ensure that members do not experience shortfalls if they make use of healthcare providers (hospitals and doctors) that the Scheme has a specific payment arrangement with (except in the case of emergencies).

We wish you a wonderful day further.

If you have any more questions, please call us on ***, email ********** or visit www.discovery.co.za

Regards Ulaysha Pillay Discovery Health (Pty) Ltd On behalf of Discovery Health Medical Scheme

0
Replies (3)
Discovery Health
Discovery Health's reply16 Apr 2018, 12:53
Official

Dear soob

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

PS
PragasenSoobramoney S's update16 Apr 2018, 13:09
Reviewer Update
My daughter was taken to a Delta network of hospitals in an emergency.Her mouth had limited opening,could not even get an energade bottle neck in her mouth.She could not eat or drink .Shebwas in excruciating pain. Her jaw was locked.Dignosis CELLUITES of the left part of her face and ab abscess with impacted upper wisdom tooth therefore surgical extraction of her wisdom teeth need to be urgently done.One of the wisdom tooth even broke into her sinus cavity,she also had an acute infection.let me rather copy and paste,it's exactly what you have. On 06 Apr 2018, at 1:48 PM, Clive Soobramoney ********** wrote: Afternoon and hope all's well.Account for Maxine Callie Soobramoney (Emergency admission) Member number 527 132 860. Kindly process claim as discussed with pre authority department and Vanessa from Discovery health at Life Entebeni hospital.All SADA CODES REFLECT ON THE INVOICE. Please note the codes IDC10 and procedure codes as reflected on invoice. Also kindly make note of the following. 1) Very bad pain from mouth area. 2) Jaw could not open. 3) Dehydration. 4) Pain came on suddenly. 5) ABSESS drainage. 6) CELLUITES swollen mouth and lymph nodes. 7) Chronic sinusitis and infection. 8) Tooth broke through her sinus cavity. 9) Could not eat or drink anything. 10)Protein shake given to her in hospital via a straw caused an allergic reaction (Chest got heavier) Doctor advised her to stop taking it. 11)Was on IV line for dehydration from day one. 12)Was on antibiotics from day one to get the swelling down. 13)Dr Patrick Uys who was contracted to discovery health retired a month ago. 13)Dr Amadais was the only Maxillofacial surgeon available at a delta hospital,even Dr Chettiar from Etheweni hospital was not available (I called him) Dr A****as is not contracted to discovery(Please note this was an emergency) 15)Breathing was very difficult. 16)After been discharged she got home and continued to vomit. I trust that the above will give one a much more clear indication on the nature of the illness/diagnosis/surgery and the reason for the emergency admission. Yours faithfully P Soobramoney (Father) ********** 973 Mrs Michelle Soobramoney (Mother) ********** 667 THERE WERE NO OTHER MAXILLOFACIAL SURGEONS AVAILABLE,IT WAS THE STARTING OF EASTER WEEKED.THE DOCTOR STILL CAME OUT AND DID THE OPERATION ON GOOD FRIDAY.WE WENT TO THE RIGHT HOSPITAL,UNFORTUNATELY THE MAXILLOFACIAL SURGEON RETIRED A MONTH AGO.WHOULD IT HAVE BEEN EASIER TO GO TO A NON APPROVED HOSPITAL,WHICH I COULD HAVE DONE.PAY THESE PMB CONDITIONS AT THE INVOICED COST BECAUSE THERE WERE NO OTHER DOCTORS AVAILABLENOW I NEED TO RETALIATE BY FILLING OUT A FORM FROM THE COUNCIL OF MEDICAL AID SCHEMES TO FIND A SOLUTION."PLEASE BEFORE YOU SEND ME A MAIN PLEASE CHECK YOUR GRAMMER.PATHETIC ! I just copied and pasted what you sent me.Refer more carefully to the act of 131 of 1998,I beg of you,please pay, you are even in possession of the maxillofacial surgeon letter of motivation of how urgent the surgery was needed.Refer letter of motivation.
Discovery Health
Discovery Health's reply18 Apr 2018, 13:56
Official

Dear soob

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

Regards
Discovery Health Servicing Team