PMB coverage dismal

<p>I developed a clot / DVT during the 6th month of my pregnancy and was put onto the CLEXANE injections to manage the DVT for the remainder of my pregnancy. I put in a PMB application with Discovery to cover these meds. DVT is on the PMB list of conditions and can be life threatening if not treated. Discovery approved this application about two months later, up to my due date which was end January. In addition to covering the drugs, they also claimed to cover the associated specialist appointment and blood works. On approval I received a call fromDiscovery notifying me of the approval, in which the consultant told me I could now go and collect my drugs for the last two months.... Bizarre for a consultant to say just absurd thing. Obviously I had collected the drugs (and paid for them) in the meantime as otherwise the clot would not be managed and I could possible be dead.</p> <p> </p> <p>Following the approval it took another few weeks and calls and follow up emails to get the drugs claim refunded. Discovery never refunded the specialist appointments or blood works as per the PMB approval but by this stage I was so over following up I let it slide as these were small amounts in comparison with the drugs that they refunded.</p> <p> </p> <p>Since then I have had my baby. She came a week early via C section. C section is a major abdominal surgery, and given the DVT I had my specialist physician prescribed that I continue on the Clexane for another 6 weeks. This physician is a well respected physician at the Sandton Clinic and as such I have no reason to discount his advice to continue on the meds. Clexane is not a fun drug to be on - it is a painful injection so I was not on it for fun. I was on it to reduce the risk of further DVT complications, especially now that I have a child to look after.</p> <p> </p> <p>I put in a new PMB application to cover this extended time and in the meantime, while waiting for approval, I collected the script from the pharmacy and the amount came off my MSA (read - it pretty much wiped out my annual MSA at about R7000 for one month). Let me reiterate that DVT is a PMB recognised condition and can be life threatening. I received notification in February that my claim was rejected, with no good reasoning. The letter did say I could submit further evidence to support my claim but they don't say what evidence they require.</p> <p> </p> <p>I put in an appeal. It took a few weeks for the appeal to be considered and I received notification last week that my claim was approved, but only for a week, not for the full six weeks. Their reasoning is that they consulted an expert but no further reasoning given. What did the expert say? How is their expert different to the specialist physician's advice, that prescribed the drugs in the first place? Why did they not let me know their expert's opinion when the claim first came through if they really didn't think I needed to be on the drugs?</p> <p> </p> <p>I considered calling Discovery to understand their decision but to be honest I am so tired of wasting my cellphone minutes getting through to the right department, only to talk to a consultant who won't know the answers. The facts are simple.</p> <p>1. I have had a DVT</p> <p>2. I had major abdominal surgery putting me at high risk of a recurring clot for a few weeks post surgery</p> <p>3. In addition to the post surgery risk, the higher levels of estrogen caused by pregnancy that cause the pregancy induced DVT in the first place only start to subside about 6 weeks after delivery.</p> <p>4. A well respected specialist physician with oodles of experience with these cases prescribed the medication for the condition</p> <p>4. I am breast feeding so alternate medication was not an option</p> <p>5. Had I not been on the Clexane and developed a recurring clot, I would have had to be hospitalised again, resulting in further costs for Discovery and a knock on effect on my baby that would then be separated from her breast feeding mother at a crucial time.</p> <p> </p> <p>I see in march 2016, Discovery had a very similar complaint from a pregnant lady on HelloPeter and subsequently settled the claim. It seems however that the learning wasn't implemented within their organisation.</p> <p> </p> <p>Discovery Health, I request the following:</p> <p> </p> <p>1. That my claims for the physician visits and blood works from the initial PMB approval are reprocessed and paid in line with the initial PMB approval</p> <p>2. That my second PMB application be reviewed in the context of ths situation - major surgery, postnatal with elevated estrogen levels, breastfeeding and specialist physician prescription, along with the fact that DVT is on the Discovery PMB list!</p> <p>3. That the opinion and advice specialist physician that prescribed the meds is respected</p> <p>4. That my subsequent claims for the six weeks following my surgery (Clexane and specialist physician appointments) are reprocessed and paid according to the PMB requirements for any life threatenting condition.</p> <p> </p> <p>Should this not be possible, please respond via written email advising me of details of why Discovery disagree with the above. Please do not get a consultant without specialist knowledge of pregnancy induced DVT's call me.</p> <p> </p> <p> </p> <p> </p> <p> </p>