Poor service

I am a Discovery KeyCare Core member and am extremely disappointed with the handling of my recent claim.

I became severely ill with acute mastitis, which deteriorated rapidly. On the KeyCare Core plan, access to hospital-level care is not possible without a specialist referral. My GP therefore arranged for a specialist consultation as this was the required pathway to assess my condition and determine whether hospital admission was necessary.

Following the specialist assessment, my GP submitted a treatment plan and Discovery authorised Hospital at Home care. Hospital at Home is only approved when hospital-level treatment is clinically indicated, confirming that my condition was serious and that the specialist consultation formed part of the same authorised care pathway.

Discovery has since rejected payment for the specialist consultation, stating that my specialist benefits for the previous benefit year were depleted. This rejection fails to take into account that:

The specialist consultation was mandatory under the KeyCare Core plan rules

It directly enabled access to authorised hospital-level care

It was not elective or discretionary, but part of a clinically necessary referral pathway

This is my first request for this claim to be settled, and it does not appear that the claim was properly reviewed in the context of DSP referral rules, PMB-related care, or authorised hospital-level treatment.

Refusing payment for a required specialist referral on a plan that mandates such referrals places members at risk and undermines access to timely care.

I am requesting that Discovery:
• Reassess this claim within the KeyCare Core benefit structure
• Confirm whether a clinical review was conducted
• Provide a written explanation should the claim remain declined

If this matter is not resolved, I will escalate it to the Council for Medical Schemes.

As a postpartum patient, this experience has been distressing and unacceptable.

I have reviewed the email correspondence. Unfortunately, it does not address the concern raised.

The email simply states that the claim was partially paid from my Personal Health Fund and that the balance was rejected due to Specialist Benefit funds being depleted. It does not explain how a mandatory specialist referral, required under the KeyCare Core plan to access hospital-level care, can be excluded from cover — especially when Discovery subsequently authorised Hospital at Home care.

Redirecting me to the same explanation does not constitute a reassessment or a clinical review of the claim.

I am requesting that Discovery address this matter substantively and confirm whether this claim has been reviewed within the KeyCare Core referral and authorisation framework. Failing resolution, I will escalate the matter to the Council for Medical Schemes.

Considering you put my life in danger by making it extremely difficult to get basic in a serious situation. With a fever of 40 and extreme pain because of the mastitis I had to come back home from the hospital after being denied assistance due to your lack of compassion, to then speak to your consultant who said the only way I can get admission is with a specialist referral which would have taken a few days to review i would have most probably be a worst of condition had my gp and specialist waited for your ****ty service.