Receiving an Authorisation Number for a Hospital Visit means NOTHING! Claim still rejected after the fact!

I've been contemplating whether I should share this - but I believe its in the best interests of the public.

Do not think that if you contact Discovery Health for Hospital authorisation that this means your claims linked to this event will be automatically considered. My wife had to go in for a major operation this year - which included oopherectomy and salpingectomy. All things I couldnt even pronounce before this ordeal. The relevant doctor provided me with the necessary ICD10 codes and I contacted Discovery authorisations department. The lady on the other end of the call proceeded to ask for all the codes, and punched them in one by one, confirming all was ok - bar one code (removal of IUD in surgery) where she asked why this wasnt done in the rooms. Reason being the doc couldnt find the strings to pull it out, and since my wife was going under the knife, best opportunity to do it all at the same time. I recieved the authorisation number - based on the codes I provided - and I thought this was it - all good. The total cost for the doctor (who is contracted out) was R48 000. I paid this cash BEFORE the surgery, with the understanding that because the procedure (based on the codes I quoted and were checked by Discovery themselves) was approved.

My wife goes for the surgery - a 3 hour operation by the way - and within a few days I get the claim result notification from discovery.

The assessed the claim, and are paying me back R6900.00. From a total of R48k. I am on the Classic Saver plan by the way! I think I vomited in my mouth at this stage. I contacted them telephonically, and explained the problem I saw with a claim of R48k, for a 3 hour op, getting refunded a disgusting R6900. The gentlement proceeded to say "Yes, I can see that, let me ask for the team to re-asses your claim". No new info was sent - no new evidence. a few days later - I receive notification. After re-assessing, they will now pay R12600 out of the total of R48k. Already here I am wondering - why the sudden "find" of another R6k? Why wasnt this done upfront? How many people are left reeling thinking things have been done right the first time? Anyways - I complain again, as I see that 1 code (line item) - the one for the largest amount of R22k - is not being considered for assessing. Back and forth on emails, complaining on social media and phone calls back and forth - to no avail.

Cut a long story short - Discovery have left me out of pocket for a total amount of R35k. Their reason being that 2 of the codes used by the doc are for the same "type" of procedure and are incidental. Therefore they will process 1 of the codes, but will not process the other. Also - taking into account I am covered for 200% of medical aid rates - and they see this op being worth only R12k. WOW.

Upon contacting the doctor, he confirmed they are NOT incidental due to what transpired in the operating theatre. He proceeded to type up a 2 page motivational letter, describing and explaining my wife entire history, why he did what he did in theatre, and how the codes used are the only codes that COULD be used. needless to say, discovery have disregarded the letter, and have kept their stance that the codes are wrong, and they will NOT pay for that line item.

This "false sense of security" around obtaining authorisation PRIOR to admittance to hospital is a FARCE. Luckily I have gap cover, so they were able to cover some of the shortfall on the line items processed by Discovery. Problem is, the same line item Discovery is refusing to process, my Gap cover cannot assist as they cover "GAPS" - not full amounts. So I have no claim there either.

The total amount that Discovery Health refunded me on my claim of R48k - a measly R12k.

Discovery were disingenuine in my opinion not only for not processing the claim properly first time round, but now to claim that the doctor does not know what he is doing and saying the codes are wrong. Who pays the price here? I do.

But I will leave you with this. According to discovery health - a 3 hour op by a professional gynaecologist, in theate - performing life saving work on a loved one - is worth R12000. KNow many doctors who would do it for that price? I dont.

Maybe this is how they are covering the multi million rand rent on their brand new head office.