URGENT COMPLAINT: Discovery Failing to Cover Life-Sustaining PMB Medication for My Child

I am submitting this as a formal and urgent complaint against Discovery Medical Aid for their ongoing and unjustifiable refusal to fully cover the life-sustaining medication required by my daughter, who was born with a rare but severe con******* condition: Tracheo-Esophageal Fistula and Esophageal Atresia (OA/TOF).

This condition is clearly listed as a Prescribed Minimum Benefit (PMB) in Discovery’s own documentation and under the Medical Schemes Act. Despite this, we have spent over three years battling for proper coverage of her essential medication—Ulsanic and Nexium. These are not optional treatments; they are internationally recognized as medically necessary for patients with OA/TOF to prevent life-threatening complications and preserve their quality of life.

In December 2024, Discovery acknowledged the seriousness of her condition by approving a limited "exemption claim" covering R1,357.96 per month, though we still paid R720 out-of-pocket. Then, without any notice or valid explanation, this exemption was revoked in May 2025, and the medication was reclassified—correctly—as a PMB. However, Discovery now covers only R240 per month, leaving us with a crushing and unjustifiable financial burden.

Let me be unequivocal: PMB conditions must be fully covered by law. Discovery’s ever-changing justifications, administrative inconsistency, and refusal to comply with regulatory obligations are not only *********—they are ********.

As paying members who contribute significantly each month with the reasonable expectation that our child’s basic, legally mandated medical needs will be met, we are appalled by Discovery’s negligence and obstruction. These actions are in direct violation of the Medical Schemes Act and put a vulnerable child’s health and life at risk.

We have escalated this matter to the Council for Medical Schemes and lodged a formal complaint. Still, Discovery continues to ignore its legal responsibilities and its ethical duty of care.

Unless the following actions are taken immediately, we will continue to publicize our experience across all available public, legal, and social channels:

Full and retroactive coverage of all medications related to my daughter’s PMB condition.

Reimbur*****t of all out-of-pocket costs that should have been covered under PMB.

Immediate correction of Discovery’s internal records, including the removal of the inappropriate “exemption claim” classification.

This issue goes beyond policy mismanagement. It is about a child’s fundamental right to health, and a medical aid scheme’s legal and moral obligation to deliver care in accordance with the law.

Further compounding this is a wealth of medical literature underscoring the necessity of long-term acid suppression therapy in OA/TOF patients. Without it, these patients face a significantly higher risk of esophagitis, esophageal strictures, Barrett’s esophagus, and esophageal cancer—a direct result of ongoing damage from acid reflux. Discovery’s refusal to cover these treatments flies in the face of established medical science and exposes my daughter to these severe, preventable complications.

We will not relent until Discovery does what is legally required and morally right: ensure our daughter has access to the treatment she needs to survive.