Not even worthy of a one-star rating!

<p>My name is Cebisile Dijana, a long standing but dissatisfied member of your scheme.</p> <p>Which is why I find having to write on this hellopeter.com page rather disparaging especially after what was such a joyful moment, such as befell us on the 22nd of June 2016. On that fateful morning, we were blessed with the birth of my beautiful baby girl and second child.</p> <p>As stated in my several emails to you – I find the fact that I have to go such lengths to refute her medical bill, which is in dispute rather distasteful - as it sheds light on the degradation of your service philosophy over the past 10 years since I’ve been a client with you. <br /> <br /> It is sad to note, on a year on year basis, that you as Discovery value me as your client - less and less, so in the same light I have made a conscious decision to transfer my Discovery Life Retirement Annuity Fund, Discovery Endowment Investment Plan(s) from Discovery to a better deserving Health and Life Provider (seeing how you rank so low in SAcsi rating) - pending outcome of your response to my dispute!</p> <p>It is no wonder the latest South African Customer Satisfaction Index (SAcsi) for medical aids in the country shows Discovery Health as being placed at a mere no.4 and at below average SAcsi (yes that being a mere 74.2) for service delivery for 2016 – no surprises there!</p> <p>The principle is simple: if you cannot value my health and that of my family which is my highest valued asset(s) – how can I trust you with any other business covering lesser assets? </p> <p>Now let’s get back to the rather apathetic gibberish that you had the nerve to send me – clearly from your pile of concocted nonsense you send out daily to most of us “shmucks”! Who, in your view, have fallen for what is increasingly becoming a pyramid-scheme called Discovery Health, which by the way is fast gaining a negative brand reputation - one only needs to see on this very page - the various complaints to attest to this!</p> <p>I write this letter on basis of principle - another word in your selective vocabulary that you have clearly lost sight of in your organization!</p> <p>That being said, after careful review of your response, please receive the following - </p> <p>In your response you wrote: “The Medical Review team has declined funding for the provider under the Prescribed Minimum Benefit stating that you used a non-designated service provider and you were aware that the doctor was not a designated service provider as you have consulted with the provider numerous times.”</p> <p>A: Allow me to point out several insinuations you have clearly taken liberty to use par creative-license of an argument and the associated questions it raises:</p> <p>1. Upon pre-authorisation of my admission to hospital to have my caesarian procedure – why is it that none of your consultants over the phone or by any other media, never at any point advised me in any way of the status of the provider?</p> <p>2. Now if you state – as by intimation, that the service provider in question is non-designated. How is it then that every invoice I have over the course of my pregnancy submitted after using said service provider has been 100% reimbursed – is that standard practice even with a non-designated service provider - as you stipulate?</p> <p>3. Your rather cavalier intimation in the above statement and I quote “and you were aware that the doctor was not a designated service provider” reeks of paralyzing ineptitude and is tantamount to defamation. I am now within legal right to ask you to produce proof of the statement that “I WAS AWARE” of the service provider’s status. I demand absolute proof of this to be produced in writing or on recording (given my numerous discussions with several of your clearly inarticulate and rather *********** call center personnel);</p> <p>4. Now if I may bring to your attention that my I have been using the same gynecologist for over 10 years now - funny enough my first pregnancy, was also delivered by the self-same service provider! Whom you suddenly claim is a “non-designated service provider” – yet upon logging into your website it is quite clear that said service provider exists on your “extensive” database. </p> <p>Now it is a matter of public record that Discovery Health is amongst the top lodged complaints, as attested by the number of cases at the Council for Medical Schemes, regarding your deviant use of PMB’s. A cleverly concealed tactic you clearly intend to continue using to de***** members and are unmistakably handsomely profiteering from! Without going too far into it, lest you find cause to vomit the same garbage you’re feeding the media and hide behind legal jargon to abdicate yourself of a clear and moral obligation to your clients in the pursuit of ********** profiteering– seeing your company lacks moral compass!</p> <p>Allow me to once again quote the bucket load of repugnant ******* you served up to me and I quote:” Prescribed Minimum Benefits (PMBs) 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.”</p> <p>Given the motivation provided by the service provider, which your medical review team clearly didn’t even bother reviewing – in the opening statements it's clearly outlined:</p> <p> </p> <p>“Cebisile had an emergency Caesarian Section on the 22nd June 2016 for the following reasons:</p> <p> </p> <p>§ Fetal distress</p> <p>§ Premature rupture of membranes (36 weeks pregnant)</p> <p>§ Cord twice around the neck</p> <p>§ Previous Caesarian Section”</p> <p>Given the evidence reflected above, it goes without saying the above medical recommendation should suffice and furthermore necessitate cover under the following PMB codes – 52N and 71N.</p> <p>Furthermore your own literature describing the access of PMB’s (Saver Health plan) it states: “You must use designated service providers (DSPs) in our network. This does not apply in life-threatening emergencies. However even in these cases, where appropriate and according to the rules of the Scheme, you may be transferred to a hospital or other service providers in our network once your condition has stabilised.”</p> <p>It is rather disconcerting that this factual recording of a trauma birth is conveniently overlooked - added to that, this clearly demonstrates (even to a lay-woman) that this without doubt would have harmed both me and my baby and as such qualifies as an emergency, had it not been timeously attended to – a fact that is clearly lost on your panel of “experts” in your Medical Review team as you clearly want to argue otherwise in your response!</p> <p> Even so if as stated accordingly – “you may be transferred to a hospital or other service providers in our network once your condition has stabilised.” Why was this not effected consequently as according to the “Scheme” seeing you argue that the service provider is “non designated” or was this conveniently and negligently overlooked in order to avoid paying full cover?</p> <p> </p> <p>Now to the penultimate point!</p> <p> </p> <p>” Please take note that a PMB condition does NOT necessarily mean a hospital admission, it can be treated in casualty, eg very low blood sugar, an acute asthma attack or a fracture.”</p> <p>Now allow me to dumb down this message – are you seriously equating a life-threatening delivery of a baby to an asthma attack? <br /> </p> <p>Secondly your statement “a PMB condition does NOT necessarily mean a hospital admission” – is facing a multiple life-threatening pregnancy at time of delivery, viewed by Discovery Health as merely having a condition that can be “treated” in casualty and which does not necessitate hospital admission - right? <br /> <br /> Tell me something Discovery, since this is women’s month - are you inferring violation of a universal right which is enshrined in our country’s Constitution Chapter 2 clause 27 – (The Right to) Health care, food, water and social security and clause 10 – (Right to) Human Dignity amongst many others!<br /> </p> <p>Are pregnant women simple animals according to Discovery’s view?</p> <p><br /> That, you can so nonchalantly state according to your degenerating argument, that as a pregnant woman, at the time, I am meant to simply deliver a child in casualty and in the same breath - simply walk out the hospital without “needing” admission as your statement insinuates?</p> <p> </p> <p>It is quite interesting to note the disingenuous change in your argument– in my earlier enquiries as to why only 25% of my claim was covered against a backdrop of 2 very lucid facts and without over-burdening the fact:</p> <p> </p> <p>1. Having been a client of Discovery Health for over 10 years – my first birth in 2011 was covered at 85% costs whilst I was on a lesser plan i.e. Delta Saver under Discovery;</p> <p>2. I have since upgraded my cover to Essential Saver - I am now faced with a situation where you as Discovery Health are now duplicitously hiding behind your infamous PMB argument and disputing paying cover;</p> <p> </p> <p>Furthermore, upon engagement with your call-center agent - on the 25 July 2016 – they made several statements that have made me question your rather disgraceful business practices! For one, when asked why Discovery Health covered only 25% of the disputed amount, they made reference to Discovery’s reasons being in line with the Council for Medical Schemes on behalf of The Department of Health’s National Health Reference Price List!</p> <p> </p> <p>Given that one of your employees made such a revealing statement – I am now compelled to demand that I am sent this Reference Price List (RPL) as app**** against emergency caesarean rates against Discovery Health rates! And before you contemplate that tired line “To protect our confidential information” may I remind you that I have every right to this information under the Promotion of Access to Information Act, No 2 of 2000 - which is protected and administrated under The Human Rights Commission. <br /> <br /> As it greatly puzzles me that an emergency caesarean according to you as Discovery Health actually costs as much as you have decided to “pay” given the amount of personnel involved. Shame on you Discovery, you’re a ****!</p> <p> </p> <p>Lastly, here are my next steps that I have endeavored to put in motion to expose your ******* and rather questionable business:</p> <p> </p> <p>1. As is evident I have already lodged complaints on several public medium made available to me as a consumer – including Facebook and HelloPeter.com and several consumer watch bodies in the media;</p> <p>2. Seeing that you have chosen to infringe on several rather universal human rights, I have in parallel process taken liberty to approach the Human Rights Commission of South Africa to lodge a complaint; </p> <p>3. Pending outcome of your response to this email – a legal team is ready to lodge a complaint with the Council for Medical Schemes and –</p> <p>4. Pending result of your response – I will exercise my rights by approaching the courts by issuing summons against you as Discovery and all the while exposing your malpractice in the media especially in light of cover for pregnant women and their associated rights!</p> <p> </p> <p>That being said – your move Discovery!</p> <p> </p> <p> </p>