PMB Declined & R8,000 Shortfall – Infant Cardiac Concern During Admission

I am extremely concerned about how Discovery Health has handled my 4-month-old son’s hospital claim.

My son was admitted to a KeyCare network hospital. During his admission, an X-ray revealed findings relating to his heart that alarmed the treating medical team. Given his age, the doctors were not willing to take any chances and urgently requested a paediatric cardiologist to assess him.

The hospital does not have a paediatric cardiologist on site, so one had to be called in. This was medically necessary and based on clinical concern — not elective or optional

Discovery paid the cardiologist at scheme rate only, leaving me with an R8,000 shortfall.

I submitted a PMB review request together with the required scans and supporting documents. The PMB was declined.

I was not informed that I could face a significant shortfall in a situation where: • The hospital is a network provider. • There was no in-network paediatric cardiologist available. • The consultation was clinically indicated due to suspected cardiac findings in a 4-month-old infant.

In an urgent in-hospital situation involving a baby, parents cannot reasonably be expected to source alternative specialists or consider network implications.

I am requesting:

A detailed written explanation for the PMB decline, including the clinical reasoning.

Clarification on how members are expected to access specialist care when no network specialist is available.

A reassessment of this claim considering the medical necessity and lack of in-network availability.

This situation has caused unnecessary financial and emotional strain during what was already a stressful medical admission for my infant.

I request urgent review and resolution.