When Caryn and AJ Venter had an emergency with their little daughter, they were shocked to discover that they were not members of Discovery Health's Classic Comprehensive Plan because of an administration error. After having to part with R17 000 and eventually ditching the medical scheme, they feel customers are expected to pay for the fund management's errors. Health24 contacted Discovery Health for a response.
How the problem started
My husband, myself and our 1-year-old daughter were on Discovery Health's Classic Comprehensive Plan. It was originally paid for by the company that my husband was working for. However, when he switched jobs we submitted a request to Discovery Health to change to private payment because we wanted to stay on that particular health plan.
Discovery told us what documentation needed to be filled in and submitted, and we duly did that. They then informed us that it was being processed, and that was the last we heard. This was at the end of March 2015.
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At the end of May, we had an emergency with our daughter. She started wheezing very suddenly at around 16:30 on Saturday May 30. I was immediately unhappy with this as I was convinced that it was not simply chestiness or the onset of a cold etc. I got hold of our paediatrician and he kindly agreed to an emergency appointment at 18:30 that evening. He agreed with me that it did not sound as though she was sick. He said it sounded as though she had inhaled something and it was starting to block the airway to her right lung. He immediately sent us through to Constantiaberg Medi-Clinic in order to get X-rays, while he got in touch with a specialist. We went and got the Xrays, and indeed something was showing up. Our paediatrician forwarded it to the specialist and gave us his number and told us to contact him in the morning.
On Sunday morning we contacted the specialist. He was not overly concerned, saying that her symptoms did not show her to be in distress and so was happy for us to come in to the hospital on Monday morning. However, as the morning progressed our daughter's wheezing became worse and she also started coughing. I was very unhappy with this and asked my husband to contact the specialist. He duly did so. The specialist agreed that given her symptoms had escalated, that it would be better for us to bring her in immediately. Since he was not on duty he referred our case to the surgeon that was on duty.
We checked in to the hospital, giving our medical aid details as is expected, under the belief that we were covered. Our daughter then had another set of X-rays and was then checked by the doctor before going into theatre for the bronchoscopy procedure.
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Thankfully, they easily found the object and were able to speedily and easily remove it from our daughter's airway. They even commended us on catching it so soon as it drastically reduced the likelihood of any side effects. Our daughter then stayed overnight in order to be monitored and make sure that all was well. On Monday morning she was given the all clear and released.
On the Wednesday June 3 the hospital contacted my husband to tell him the claims they had submitted to Discovery had been rejected because our membership had been cancelled as of March 31. I am sure you can imagine our shock and surprise. My husband called me and asked me to contact Discovery and find out what was going on.
On contacting Discovery, I was told that indeed they had cancelled our membership. I asked why, when we had expressly requested to be moved to private payment in order to remain on this particular plan. They then told me that they received the request with all the relevant documentation, but it was not processed because I had submitted it and not my husband. I asked why it was not made expressly clear to us that my husband had to personally request this, during the initial inquiry; and why after receiving the request from us why they did not contact either myself or my husband to check. They have cell numbers and email addresses for both myself and my husband. If they could not get hold of me on my cell, why did they not email? Why did they not call my husband to check he had indeed authorised this request (as shown in the documentation submitted to them), why did they not email him if they thought it was a request made to his account fraudulently? They could not answer me. All they said was that my husband would have to contact them.
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He called them that evening, they said they would call him back. To date we are actually still waiting on that particular call to come through. My husband then called them on the Thursday morning to try and resolve this issue. They then informed us that we would need to pay two months premiums upfront in order to be reinstated (for the two months that we were not actually on the plan, through their error) so that the hospital claims would be covered because it would mean there was no break in cover.
We were very unhappy about this, as it was their error that resulted in the situation. We had just moved house in May, so money was tight. However, we paid the requested amount and submitted the relevant documentation and were told that systems were down, but we would be reinstated within three days.
I then contacted Jashvir Singh, their Executive Relationship Manager, to ask for the situation to be resolved, and whether we could make a payment plan to catch up. We did not disagree that the premiums needed to be paid, we asked simply that we could pay one month's premium upfront, and pay the second month off over three months, but that going forward we would pay each months premium as needed because we could afford it. R17 000.00 upfront is a lot of money. We felt it would be fair for them to allow a payment plan since it was their error that resulted in the situation. We were refused.
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Discovery then emailed my husband requesting details of our daughter's hospitalisation before they could proceed with the reinstatement. We then submitted the information, clearly stating that it was not a pre-existing condition but an emergency situation resulting from an accidental injury and could therefore not affect reinstatement.
I then went into the Discovery offices in Century City to see a consultant in order to try and get this situation resolved.
I saw the consultant David Brown, he was very friendly and helpful. He managed to get hold of all the relevant people and find out why the various departments were clearly not communicating properly and what further information was needed. I was also told during the consultation that part of the worry was that we were simply trying to get reinstated simply to get the hospital bills paid and that we would leave the scheme again once those bills had been paid. Can you imagine my surprise! Considering we were under the impression that we were covered, why would be doing that? If we simply wanted the bills paid, why would we not pay them instead of paying R17 000.00 to get reinstated to a medical plan we were never meant to have been removed from in the first place? Why would we have applied to move to private two months before the incident and supplied all the required information? It was a ludicrous suggestion.
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Apparently they needed the hospital report. Why no one could tell my husband or me that this was what was needed I still do not know. David requested that information from the hospital and duly received it.
So we stopped asking for a payment plan, and agreed to just grin and bear it because we were going to be reinstated without a problem now that all the relevant information had been submitted and the misunderstanding cleared up.
We were then informed that this was not enough, that they needed the full report from the surgeon. This they duly received as well.
Then Discovery emailed my husband on the evening of Monday June 8 once more requesting information about our daughter's hospitalisation. Both my husband and I were furious at this stage. How many more times would we have to submit the same information?
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Then on Tuesday June 9, David phones us to say he has been informed that we will not be reinstated, but will have to apply for a completely new membership because the surgeon could not give a 100% verdict that no complications could arise from the emergency operation. This is despite the fact that the doctor said it was caught exceptionally early and that our daughter was showing no signs of scaring or complications, and that she had had a follow up with the surgeon and the surgeon said that the chances of her developing complications now was exceptionally small.
Apparently Discovery's system had been down again and so David had not seen my emails until Tuesday morning.
Needless to say we are appalled at this entire situation. Discovery has been messing us around this entire time, all due to their own mistake. We informed them that we will not be applying for membership with them ever again after the dismal manner in which this situation was dealt with. They will however be refunding us our R17 000.00, but not the interest they have accrued on it since it was deposited.
Discovery has stated that everything was in line with "the rules of the scheme" - this may or may not be true but it certainly means that the public ought to be aware that apparently the Discovery Health's scheme operates under a rule that customers are expected to pay for the fund management's errors.
Discovery Health responds:
Health24 checked in with Discovery Health Reputation Manager Nozuko Basson. She responds:
Discovery Health Medical has a responsibility to follow due process to protect the funds of members of the Medical Scheme. That is why we apply certain underwriting rules and ask applicants to provide certain health details when making changes to their membership.
In this case, it is correct that there was an application for Mr and Mrs Venter to move from an employer group to a membership in private capacity. We sent an email about this application on March 28 2015 indicating that we needed the change in banking details to be confirmed by the main member on the plan. There was no further correspondence after this.
Discovery Health Medical Scheme aims to activate memberships as soon as possible with the necessary information. We hope applicants also contact us if there is an undue delay. We usually confirm membership, any changes to memberships, the updated debit order date and terms of cover in writing as soon as everything is in order – even if it is only considered a transfer in membership. Mrs Venter and her husband did not receive any confirmation of membership from us. There were no enquiries about membership or contributions until May 26 2015 when a hospital account was submitted to the Medical Scheme.
We requested the necessary contributions and health information to reinstate their membership from April 2015. No break in membership or short payment of contributions would be possible for them to have their full benefits. Therefore, we requested payment of the full contributions for April and May 2015. On reviewing the health information on the forms we required; however, full details of the medical emergency were not provided. The Medical Scheme declined the reinstatement of that membership, refunded their contributions, and requested that a new application be completed for a new membership of Discovery Health Medical Scheme.
We did, within applying the rules of the Scheme, try to assist in the reinstatement of their previous membership. Given the break in membership and the details provided, it was not possible for us to do so without a new application for membership being completed.
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