Trying to avoid paying for PMB
<p>I was attacked by a dog in the street on 13 March and fell,breaking my wrist badly. I had to go to Vincent Pallotti Hospital,an hours drive away,as it is the only hospital that Discovery allows on my plan.</p> <p>As it was a Sunday,I was treated and x-rayed in the Emergency Unit and told to return next day at 7 a.m !! This I did,getting up at 4 a.m. The Orthopaedic Surgeon there tod me that he could only operate the next day and wanted to admit me. I saved Discovery the overnight costs,by just returning again at 7 the next morning....</p> <p>So far so good,but now Discovery are refusing to pay the full Surgeon`s bill,as well as his and the follow up physiothe****** bills.</p> <p>Their reason? " This is not a PMB case,as I was only operated on 2 days later".. That was not my fault---I went to their designated hospital and was treated by the only orthopaedic practice there... The Surgeon`s account refers to PMB emergency surgery,which Discovery obviously does not accept. </p> <p>Code S 52.50 covers this PMB case ,according to all of the medical practitioners involved. Why does Discovery dispute the word of the professionals ?</p> <p>I have seen on the Internet that some medical aid companies have been trying to deny PMB bills--sad to see that Discovery have joined their ranks....</p> <p>I have consulted the Council for Medical Schemes website and my case is an obvious example of " emergency surgery," qualifying as a PMB case. The fact that surgery was not immediately carried out was,as I have stated ,not my fault,yet Discovery are electing to use this as a loophole to avoid paying.....</p>
Thank you for speaking to me and allowing me to investigate your query.
After investigating your case I can confirm that your condition does form part of the Prescribed Minimum Benefit (PMB) list. However, it was not an emergency medical condition as explained via email and telephonically. The reason for this is that you were injured on 13 March 2016 but your surgery was only done on 15 March 2016. Therefore, you did not receive immediate medical treatment, as mentioned in the definition of an emergency medical condition.
We do understand that the delay in treatment was not due to any fault of your own. However, for us to be fair to all of our members we must consistently apply the rules set out by the Act and the Scheme. When an admission is voluntary and the member chooses the claims to be paid as a PMB, designated service providers (DSP) must be used to have the claims funded at cost.
I am sorry that the funding decision could not be changed. However, you may contact us directly for further assistance.
Regards
Jashvir
Thank you for speaking to me and allowing me to investigate your query.
After investigating your case I can confirm that your condition does form part of the Prescribed Minimum Benefit (PMB) list. However, it was not an emergency medical condition as explained via email and telephonically. The reason for this is that you were injured on 13 March 2016 but your surgery was only done on 15 March 2016. Therefore, you did not receive immediate medical treatment, as mentioned in the definition of an emergency medical condition.
We do understand that the delay in treatment was not due to any fault of your own. However, for us to be fair to all of our members we must consistently apply the rules set out by the Act and the Scheme. When an admission is voluntary and the member chooses the claims to be paid as a PMB, designated service providers (DSP) must be used to have the claims funded at cost.
I am sorry that the funding decision could not be changed. However, you may contact us directly for further assistance.
Regards
Jashvir