Pathetic and shameful service and business practice

<p>Dear Adrian Gore Date: 16 March 2017<br />Discovery CEO<br /> <br />Main member: Taren Jade Van Reenen<br />Medical aid member number: ********** 30<br /> <br />Enquirer: Noellan Adams<br />Contact number: ********** <br />Email address: ********** ********** /> <br />My fiancé in October 2016 joined Discovery medical aid via the company she works for as this is their staff medical aid, we then in the week of 25 November 2016 found out that she was pregnant and contacted the medical aid call centre on three or four occasion between the week on the 25th November and the end of December to inform them she is pregnant, we also them to confirm if there is any waiting period and what hospitals/gynaecologist could be used, they provided this information and confirmed everything is in order.<br /> <br />We then contacted a few hospitals on the list provided as well as gynaecologist and then chose a hospital.<br /> <br />- Our first scan was on 28 November 2016 which we paid for ourselves. This was just a scan as we wanted confirmation that she is indeed pregnant.<br /> <br />- I first check-up with an actual gynaecologist was 23 January 2017 (which discovery paid for and I attach confirmation of this).<br /> <br />- On 23 January 2017 the gynaecologist then sent us for various blood test which related to her pregnancy and this was also paid for by the medical aid (I’ve attached proof of this).<br /> <br />- On 24 February we went for our second check-up with the gynaecologist and this was also paid for by the medical aid (I’ve attached proof of this).<br /> <br />- On 10 March 2017 we then went for our third check-up and discover now refused to pay this. (this was confirm by CRM Mikella Maio)<br /> <br />During our second and third check-up with the gynaecologist we submitted our preauthorisation for the hospital stay and this was declined without any reasoning. My Fiancé received an email on 02 March 2017 declining/rejecting the pre authorisation and all it said was “unfortunately we will not pay for the requested admission for the following reason(s): We have not approved the request: Please call our call centre if you need further information (the email received has been attached). I would like to know how this explains anything.<br /> <br />After this email was received I had to spend hours on the phone on both the 02/03/2017 as well as the 03/03/2017 to figure out why it was declined. I was then informed that they were unable to provide me with this information as I am not the main member, I asked if my fiancé could call in and confirm that the information could be provided to me, they said it was not allowed unless we were next to each other (this didn’t make sense as the same confirmation would be given whether we were next to each other or not). They then informed me that I needed to complete a form and have her sign it which I did and sent it in (find attached).<br /> <br />On 03/03/2017 I called in @ 10:25am and spoke to Temba Nthembu (Consultant) who explained why it was declined to the best of his ability (wasn’t of much help and lacked the knowledge to provide a reasonable and sensible reason why. I then asked him to transfer me to his team leader.<br /> <br />They kept me waiting for 15minutes while he was supposedly looking for a team leader.<br /> <br />On 03/03/2017 @ 10:56 I spoke to Viwe frans (Team Leader) who explained that they declined the claim as she was pregnant before joining the medical aid and we did not disclose this information. I then informed him that we were unable to disclose something we were not aware of and we called in December to inform the medical aid once we had found and they confirmed all is in order and there is no waiting period. I also pointed out that the application states it should be completed honestly and to the best of your ability which was done and I asked him if is saying we ****, he then became very defensive, raised his voice and started getting upset and irate. My question to him was why does discovery accept the application in good faith, deduct 5 months medical aid fees, pay three claims and then have an issue when it comes to paying the biggest bill, he couldn’t answer me and kept saying it was a pre-existing condition (seems like a general response and he wasn’t basing his feedback on the merits of the case). I also asked him why Discovery does not give all new members an HIV test, pregnancy test and all other tests to avoid such situation because they shape their rules to suit them and not the client. He couldn’t provide me with a reasonable response. He then referred me to a CRM.<br /> <br />I was on hold for another 15minutes while waiting to speak to a CRM.<br /> <br />On 03/03/2017 (Ref: ********** 847) I spoke to Mikella Maio (CRM) and explained the above information again. She then informed me that they would require a letter of motivation from my Fiancé’s gynaecologist which would be sent to the underwriters to contest the decision to implement a 1 year condition specific restriction on my fiancé’s medical aid. She informed me that she would contact her gynaecologist and get the requested letter but this was never done and I ended up getting it myself. She wasn’t able to help me.<br /> <br />My fiancé then received a call on 03/03/2017 (Ref: ********** 789) form someone in the underwriting are to confirm her claim was declined. This shows there is no communication between the various departments, the provided us with the same information even though we were in the process of appealing the decision.<br /> <br />On 10/03/2017 I sent a motivational letter received from our gynaecologist confirming when he first saw us. (find attached)<br /> <br />On 14/03/2017 my fiancé received an email from the office of Dr TD Kretzmar (Medical consultant of the review board) confirming they would not cover the claim as this was a pre-existing condition (same as previously mentioned even though we sent a letter of motivation. I’m not sure why this email was sent to her even though I was the one who sent in all the information and I was the enquirer in this instance.<br /> <br />On 14/03/2017 @15:30pm I called Dr TD Kretzmar. I informed him that the call centre informed us that there was no waiting period and explained everything again. He informed me that they would get all the calls and give me feedback by close of business 15/03/2017.<br /> <br />No feedback was received and I was never contacted, I then had to call in myself on 16/03/2017.<br /> <br />On 16/03/2017 @ 09:45am & 10:19am I called Dr TD Kretzmar and there was no answer<br /> <br />On 16/03/2017 @ 11:15am I called Dr TD Kretzmar. He informed me that they still did not receive the calls even though Dashika informed me that feedback would be received by close of business 15/03/2017. Dr TD Kretzmar was rude and insensitive and wouldn’t allow me to speak.<br /> <br />On 16/03/2017 @ 12:20pm Dr TD Kretzmar called me and gave a bogus reason why they won’t approve the admission. He was once again rude, arrogant and condescending.<br /> <br />I also asked him to make the calls available as he only referred to one call and not all as I requested. He informed me that I would have to ride all the way to the discover head office in order to listen to the calls. This is unfair as I now have to go on the information provide by Dr TD Kretzmar as I am unable to verify it myself, I know what was said when we called the call centre. I also asked him if I could get a copy of the original application in order to read the terms, he gave me attitude and then informed me that he would get someone to send it to me as this isn’t his job.<br /> <br />My fiancé is now 8 months pregnant and this has caused unnecessary stress and sleepless nights, I expect this to be resolved by the end of this week as this is unacceptable. What happened to the customer first?<br /> <br />You as discovery with be held liable if anything happens to my fiancé due to your inability to use common sense and not provide us with a general response. This will be taken to the OMBUD is it is not resolved.<br /> <br />Our expected due date is 15 April 2017 and there is very little time remaining, I hope who ever reads this sees the urgency of the matter unlike the various people I previously dealt with.<br /> <br />Kind Regard<br />Noellan Adams</p>