BR
Benita R
1 reviews | Active since Dec 2014
05 Jan 2026, 12:39
Unacceptable Service Delays and Failed Support - Executive Plan Member
This complaint is with reference to the profoundly inadequate service and support I have received from Discovery Health, particularly in relation to unresolved claims and a dysfunctional contact centre. On 5 December, I used the Discovery app to query a number of claims submitted in December. My dashboard indicated reimbur*****t dates which had passed without payment being made. I was connected to a consultant named Sanele, who stated they would investigate why payment for one specific claim had not been released. I was placed on hold and, after waiting without any feedback or update, the call was terminated after 15 minutes. I immediately called back, queued for 12 minutes and 12 seconds, and was connected to another consultant whose name was inaudible. Before I could even ask them to confirm their details or explain the situation, this second call was also cut off. As a member on an Executive Plan, I pay a substantial premium specifically for the administration of my benefits and the expectation of efficient service. It is completely unacceptable that Discovery appears to be so inadequately staffed, especially during the critical year-end period. By 5 January, one reasonably expects a fully operational and competent administration team. Instead, I am facing lengthy delays in reimbur*****t for legitimate claims and attempting to navigate a call centre that, based on today's experience, is both understaffed and dysfunctional. According to my claims dashboard, reimbur*****ts are overdue for claims pertaining to the following providers: Danica Van Zyl Juanita Fourie C G Smith Dr. Nash I have fulfilled my obligations as a member, and Discovery must fulfil its contractual and service obligations to me. I expect the following: The immediate release of all outstanding reimbur*****ts for the claims listed above. Written confirmation sent to me without delay once these payments have been processed. A formal explanation for the systemic failure in your contact centre and claims processing department during this period. This level of service is far below the standard promised and paid for. I await your urgent resolution and response. This is not the first complaint of this nature I have had to make over the past year. Am also noting that the app is currently dysfunctional too - fails to load pages and keeps generating an error message when one selects a "personal health pathway" option for more information
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Replies (3)0
Replies (3)
Discovery Health's replyOfficial
05 Jan 2026, 12:55Dear Benita
We’ve noted your concerns and we’re investigating the matter. We’ll contact you with feedback as soon as possible.
We’ve noted your concerns and we’re investigating the matter. We’ll contact you with feedback as soon as possible.
Regards
Discovery Health Servicing Team
Discovery Health's reply05 Jan 2026, 12:55
Official
Dear Benita
We’ve noted your concerns and we’re investigating the matter. We’ll contact you with feedback as soon as possible.
We’ve noted your concerns and we’re investigating the matter. We’ll contact you with feedback as soon as possible.
Regards
Discovery Health Servicing Team
BR
I refer to the letter issued under the signature of the Chief Operating Officer regarding the retrospective “correction” of medicine claims processed between January and December 2025. While the letter provides background on the nature of the system error, it does not cure the fundamental procedural unfairness of the remedy Discovery now seeks to impose. This correspondence constitutes my formal rebuttal.
Acceptance of Error Does Not Justify Retrospective Member Liability
Your letter expressly acknowledges that:
The existence of an internal error is not disputed. However, it does not follow in law or regulation that Discovery may retrospectively transfer the financial consequences of that error to members. An admitted scheme-side system failure is an operational risk borne by the Scheme, not by members who acted in good faith on approvals issued by Discovery at the point of service.
Point-of-Sale Approval Creates Legitimate Reliance
The claims in question were:
Discovery’s real-time adjudication system exists precisely to:
Had the claims truly been subject to co-payments, SPG liability, or exclusion from ATB accumulation, they should have been declined or partially approved at the pharmacy. That did not occur. Once medicine has been dispensed following scheme approval, the member is irreversibly prejudiced and cannot mitigate the cost. Retrospective reversal in these circumstances is procedurally unfair.
Retrospective Reprocessing Is Not Supported by Scheme Rules
Your letter states that the correction is required to ensure benefits align with Scheme rules. However:
Absent such a rule, the reprocessing is ultra vires and unenforceable.
Regulatory Non-Compliance
The approach outlined in your letter remains inconsistent with the Medical Schemes Act and its Regulations, including but not limited to:
Repayment Plan Proposal Is Rejected
The proposal to “arrange a repayment plan” is premature and rejected. One cannot agree to repay an amount that is lawfully disputed and not validly due. Any attempt to debit, collect, or reflect this amount as arrears while the dispute remains unresolved will be regarded as procedurally improper and will be raised expressly with the Council for Medical Schemes.
Formal Position and Demand
My position is therefore as follows:
I hereby formally demand, within 10 (ten) business days, written confirmation that:
Failing this, I will proceed with escalation to the Council for Medical Schemes, submitting this letter and your correspondence as evidence that Discovery seeks to transfer the consequences of an admitted system failure to a member, contrary to the regulatory framework.
This correspondence is sent without prejudice, and all rights are expressly reserved.
Benita R's updateReviewer Update
05 Jan 2026, 13:44Upon writing this complaint my attention was drawn to other complaints about an alleged processing error by Discovery made by scores of other members. This prompted me to check my personal email account and I found the same correspondence from the COO. The following is my formal rebuttal to this correspondence from Discovery.To: Discovery Health Medical Scheme – Office of the COO / Compliance Department
Dear Sir / Madam,
I refer to the letter issued under the signature of the Chief Operating Officer regarding the retrospective “correction” of medicine claims processed between January and December 2025. While the letter provides background on the nature of the system error, it does not cure the fundamental procedural unfairness of the remedy Discovery now seeks to impose. This correspondence constitutes my formal rebuttal.
Acceptance of Error Does Not Justify Retrospective Member Liability
Your letter expressly acknowledges that:
· A claims processing error occurred within Discovery’s systems;
· Claims were approved and paid at 100% of the Discovery Health Rate when they should not have been;
· As a result, members allegedly received “more cover than qualified for”.
The existence of an internal error is not disputed. However, it does not follow in law or regulation that Discovery may retrospectively transfer the financial consequences of that error to members. An admitted scheme-side system failure is an operational risk borne by the Scheme, not by members who acted in good faith on approvals issued by Discovery at the point of service.
Point-of-Sale Approval Creates Legitimate Reliance
The claims in question were:
· Submitted electronically by the pharmacy;
· Approved in real time by Discovery’s systems;
· Dispensed on the basis of that approval.
Discovery’s real-time adjudication system exists precisely to:
· Apply benefit rules correctly;
· Identify co-payments or self-payment gaps immediately;
· Prevent post-dispensing disputes.
Had the claims truly been subject to co-payments, SPG liability, or exclusion from ATB accumulation, they should have been declined or partially approved at the pharmacy. That did not occur. Once medicine has been dispensed following scheme approval, the member is irreversibly prejudiced and cannot mitigate the cost. Retrospective reversal in these circumstances is procedurally unfair.
Retrospective Reprocessing Is Not Supported by Scheme Rules
Your letter states that the correction is required to ensure benefits align with Scheme rules. However:
· No specific registered rule has been cited that permits the retrospective reversal of approved and settled pharmacy claims to the detriment of a member;
· No rule has been identified that allows Discovery to retrospectively impose co-payments that were not communicated at the point of sale.
Absent such a rule, the reprocessing is ultra vires and unenforceable.
Regulatory Non-Compliance
The approach outlined in your letter remains inconsistent with the Medical Schemes Act and its Regulations, including but not limited to:
· Regulation 5 – Benefits must be determined in accordance with registered rules, not retrospectively reinterpreted following system failures;
· Regulation 7 – Rules must be app**** fairly and consistently; retrospective corrections without prior notice or uniform remediation are neither;
· Regulation 8 – Proper and reliable financial records are required; an admitted system error undermines reliance on retrospective recalculations;
· Regulation 15 – Members are entitled to clear, timeous, and accurate information regarding liabilities before amounts are reflected as due;
· Regulation 17 – Meaningful dispute resolution is impossible where liability is imposed first and explained later.
Repayment Plan Proposal Is Rejected
The proposal to “arrange a repayment plan” is premature and rejected. One cannot agree to repay an amount that is lawfully disputed and not validly due. Any attempt to debit, collect, or reflect this amount as arrears while the dispute remains unresolved will be regarded as procedurally improper and will be raised expressly with the Council for Medical Schemes.
Formal Position and Demand
My position is therefore as follows:
1. Claims approved and paid at the point of sale may not lawfully be retrospectively reversed due to Discovery’s internal errors;
2. The alleged amount of R 5210.26 is disputed in full and is unenforceable;
3. The appropriate remedy is internal correction by the Scheme, not member repayment.
I hereby formally demand, within 10 (ten) business days, written confirmation that:
· The retrospective reversals have been withdrawn; and
· The alleged member liability has been reversed in full.
Failing this, I will proceed with escalation to the Council for Medical Schemes, submitting this letter and your correspondence as evidence that Discovery seeks to transfer the consequences of an admitted system failure to a member, contrary to the regulatory framework.
This correspondence is sent without prejudice, and all rights are expressly reserved.
Note well: The substantive arguments in this letter were drawn from another member’s complaint on Hellopeter regarding the same issue.
BR
Benita R's update05 Jan 2026, 13:44
Reviewer Update
Upon writing this complaint my attention was drawn to other complaints about an alleged processing error by Discovery made by scores of other members. This prompted me to check my personal email account and I found the same correspondence from the COO. The following is my formal rebuttal to this correspondence from Discovery.To: Discovery Health Medical Scheme – Office of the COO / Compliance Department
Dear Sir / Madam,
I refer to the letter issued under the signature of the Chief Operating Officer regarding the retrospective “correction” of medicine claims processed between January and December 2025. While the letter provides background on the nature of the system error, it does not cure the fundamental procedural unfairness of the remedy Discovery now seeks to impose. This correspondence constitutes my formal rebuttal.
Acceptance of Error Does Not Justify Retrospective Member Liability
Your letter expressly acknowledges that:
· A claims processing error occurred within Discovery’s systems;
· Claims were approved and paid at 100% of the Discovery Health Rate when they should not have been;
· As a result, members allegedly received “more cover than qualified for”.
The existence of an internal error is not disputed. However, it does not follow in law or regulation that Discovery may retrospectively transfer the financial consequences of that error to members. An admitted scheme-side system failure is an operational risk borne by the Scheme, not by members who acted in good faith on approvals issued by Discovery at the point of service.
Point-of-Sale Approval Creates Legitimate Reliance
The claims in question were:
· Submitted electronically by the pharmacy;
· Approved in real time by Discovery’s systems;
· Dispensed on the basis of that approval.
Discovery’s real-time adjudication system exists precisely to:
· Apply benefit rules correctly;
· Identify co-payments or self-payment gaps immediately;
· Prevent post-dispensing disputes.
Had the claims truly been subject to co-payments, SPG liability, or exclusion from ATB accumulation, they should have been declined or partially approved at the pharmacy. That did not occur. Once medicine has been dispensed following scheme approval, the member is irreversibly prejudiced and cannot mitigate the cost. Retrospective reversal in these circumstances is procedurally unfair.
Retrospective Reprocessing Is Not Supported by Scheme Rules
Your letter states that the correction is required to ensure benefits align with Scheme rules. However:
· No specific registered rule has been cited that permits the retrospective reversal of approved and settled pharmacy claims to the detriment of a member;
· No rule has been identified that allows Discovery to retrospectively impose co-payments that were not communicated at the point of sale.
Absent such a rule, the reprocessing is ultra vires and unenforceable.
Regulatory Non-Compliance
The approach outlined in your letter remains inconsistent with the Medical Schemes Act and its Regulations, including but not limited to:
· Regulation 5 – Benefits must be determined in accordance with registered rules, not retrospectively reinterpreted following system failures;
· Regulation 7 – Rules must be app**** fairly and consistently; retrospective corrections without prior notice or uniform remediation are neither;
· Regulation 8 – Proper and reliable financial records are required; an admitted system error undermines reliance on retrospective recalculations;
· Regulation 15 – Members are entitled to clear, timeous, and accurate information regarding liabilities before amounts are reflected as due;
· Regulation 17 – Meaningful dispute resolution is impossible where liability is imposed first and explained later.
Repayment Plan Proposal Is Rejected
The proposal to “arrange a repayment plan” is premature and rejected. One cannot agree to repay an amount that is lawfully disputed and not validly due. Any attempt to debit, collect, or reflect this amount as arrears while the dispute remains unresolved will be regarded as procedurally improper and will be raised expressly with the Council for Medical Schemes.
Formal Position and Demand
My position is therefore as follows:
1. Claims approved and paid at the point of sale may not lawfully be retrospectively reversed due to Discovery’s internal errors;
2. The alleged amount of R 5210.26 is disputed in full and is unenforceable;
3. The appropriate remedy is internal correction by the Scheme, not member repayment.
I hereby formally demand, within 10 (ten) business days, written confirmation that:
· The retrospective reversals have been withdrawn; and
· The alleged member liability has been reversed in full.
Failing this, I will proceed with escalation to the Council for Medical Schemes, submitting this letter and your correspondence as evidence that Discovery seeks to transfer the consequences of an admitted system failure to a member, contrary to the regulatory framework.
This correspondence is sent without prejudice, and all rights are expressly reserved.
Note well: The substantive arguments in this letter were drawn from another member’s complaint on Hellopeter regarding the same issue.
Discovery Health's replyOfficial
07 Jan 2026, 14:17Dear Benita
Please check your emails for final feedback from us.
Regards
Discovery Health Servicing Team
Discovery Health's reply07 Jan 2026, 14:17
Official
Dear Benita
Please check your emails for final feedback from us.
Regards
Discovery Health Servicing Team