NO
Nicole O
1 reviews | Active since Oct 2019
11 Oct 2019, 14:57
PMB CONDITION (EMERGENCY PROCEDURE) not being paid even though their rules state they have to!
i had my baby on the 24th July 2018 and was an emergency due to prem labour and complications. i had a difficult pregnancy and i had selected a non DSP to discovery on my plan and i accepted that. when i went into prem labour i contacted the doctor at the Hilton Life hospital and they advised me to get to the hospital within 20 minutes as i needed to have an emergency c section. when i got to the hospital emergency they had taken me directly to maternity where they prepped me for theater where the hospital had called Dr Hadley Grave who was (on call) as well as the doctor at the hospital at the time.. Lucky for me all went well and the delivery was a success. he then advised because being an emergency the claim would be as a PMB Condition. so i would not need to worry about any shortfalls. as time has passed and claims where processed, i received an account from Hadley graves accounts to say that there was a R 21 000 shortfall. i contacted the medical aid, and they argued the case that they would not cover him as he was a not a DSP and that he was my selected doctor. i then did research once again as this happened in my last pregnancy and that was ended up claimed as a PMB condition. Anyway..... i did the research and have been advised, that in a PMB condition (EMERGENCY SITUATION) regardless the doctor is a NON DSP to my plan, it would be covered in full. because it was an EMERGENCY! secondly, the medical aid had acknowledged that this procedure was a PMB condition because they paid the anesthetist as a PMB and paid his high bill in full. so correct me if i am wrong, but how can they pay the one doctor as a PMB condition and is also above medical rates, but not the doctor who is doing the emergency delivery? i have laid a complaint with the Council of Medical Schemes complaint 71672, but this has been going on for 14 months now and have had a lack of communication and don't seem to be getting anywhere with my complaint. my case has been handed over to a consultant several times even emails to their superior to get answers but still nothing! i was advised over 5 weeks ago that they would contact me the friday with the ruling...... but still NOTHING. I am not sure what else i can do as i have been advised this is a valid case and must pursue it. but i have come to a dead end. Discovery has done this like i said in my first pregnancy with the same issues. I'm having endless issues. i pay a premium rate every month R 6072.00 for medical aid and this is how we get treated. i don't go to hospital often or claim things besides savings, its ridiculous.
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Replies (5)0
Replies (5)
Discovery Health's replyOfficial
11 Oct 2019, 16:22Dear Nicole Olivier
Your concerns are important to us and we will be in touch soon with an answer to your comments.
Regards
Discovery Health Servicing Team
Your concerns are important to us and we will be in touch soon with an answer to your comments.
Regards
Discovery Health Servicing Team
Discovery Health's reply11 Oct 2019, 16:22
Official
Dear Nicole Olivier
Your concerns are important to us and we will be in touch soon with an answer to your comments.
Regards
Discovery Health Servicing Team
Your concerns are important to us and we will be in touch soon with an answer to your comments.
Regards
Discovery Health Servicing Team
NO
Nicole O's updateReviewer Update
21 Oct 2019, 11:34So....
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.
and this is the response i get.....
Membership number: ***
Reference number: ***
Dear Mrs Olivier
Thank you for your email and I trust that you are well.
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
If you have any more questions, please visit www.discovery.co.za to log a query or call us on ***.
I trust that this information provided is in order.
Regards
Dayne Meyer
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
NO
Nicole O's update21 Oct 2019, 11:34
Reviewer Update
So....
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.
and this is the response i get.....
Membership number: ***
Reference number: ***
Dear Mrs Olivier
Thank you for your email and I trust that you are well.
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
If you have any more questions, please visit www.discovery.co.za to log a query or call us on ***.
I trust that this information provided is in order.
Regards
Dayne Meyer
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
NO
Nicole O's updateReviewer Update
21 Oct 2019, 11:35So....
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.
and this is the response i get.....
Membership number: ***
Reference number: ***
Dear Mrs Olivier
Thank you for your email and I trust that you are well.
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
If you have any more questions, please visit www.discovery.co.za to log a query or call us on ***.
I trust that this information provided is in order.
Regards
Dayne Meyer
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
NO
Nicole O's update21 Oct 2019, 11:35
Reviewer Update
So....
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.
and this is the response i get.....
Membership number: ***
Reference number: ***
Dear Mrs Olivier
Thank you for your email and I trust that you are well.
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
If you have any more questions, please visit www.discovery.co.za to log a query or call us on ***.
I trust that this information provided is in order.
Regards
Dayne Meyer
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
NO
Nicole O's updateReviewer Update
21 Oct 2019, 11:37So....
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.
and this is the response i get.....
Membership number: ***
Reference number: ***
Dear Mrs Olivier
Thank you for your email and I trust that you are well.
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
If you have any more questions, please visit www.discovery.co.za to log a query or call us on ***.
I trust that this information provided is in order.
Regards
Dayne Meyer
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
NO
Nicole O's update21 Oct 2019, 11:37
Reviewer Update
So....
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
this is the response i get:
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED?:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.
and this is the response i get.....
Membership number: ***
Reference number: ***
Dear Mrs Olivier
Thank you for your email and I trust that you are well.
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
If you have any more questions, please visit www.discovery.co.za to log a query or call us on ***.
I trust that this information provided is in order.
Regards
Dayne Meyer
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
Discovery Health (Pty) Ltd
On behalf of Discovery Health Medical Scheme
NO
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED? as it clearly states they should:
Nicole O's updateReviewer Update
21 Oct 2019, 11:39So....
this is the response i get:
this is the response i get:
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED? as it clearly states they should:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.
NO
Nicole O's update21 Oct 2019, 11:39
Reviewer Update
So....
this is the response i get:
this is the response i get:
Council complaint
We have received feedback from our Council Liaison Manager that Discovery Health have maintained their decision regarding the claim for CJH Grave. The Council of Medical Schemes (CMS) will revert to you directly with their ruling concerning your case.
As basic as this, and i must just accept? no one has contacted me with regards to ruling.
can anyone advise on this as to why its NOT COVERED? as it clearly states they should:
Definition:
PMB’s are a feature of the medical Schemes Act, in term of which medical schemes have to cover the costs related to the diagnosis, treatment and care of
· Any EMERGENCY MEDICAL CONDITION
Which conditions are covered?
In 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
· Pregnancy and childbirth – Antenatal and obstetric care requiring hospitalization, including delivery
Emergency medical conditions
An emergency medical condition means the sudden and, at the time, unexpected onset of health condition that requires immediate medical treatment and/or operation.
Designated Service Providers
When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.