Discovery Health not paying R46k - Advice needed

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AntonioDA

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Hi there

I am in need of some advice. I think discovery Health is just taking a chance, I really do think they should pay. (please excuse my spelling mistakes, I tend to make them when I type quick, when I'm angry!)

I have a Discovery Essential Saver plan with a GAP cover, which to me, from what I signed for was a 100% full hospital plan with a saving account. GAP cover will cover anything more than 100% in hospital.

So here's my story

Ok, 29 November 2011 my 2nd son was born through cesarean. All went well, baby is well. 11 days later, my wife woke up and her undergarments was full of blood. When she sat on the toilet and blood poured out like water, NOW IT WAS AN EMERGENCY. Basically (from what I understand), when the placenta was removed, it was suppose to for a scar on the womb, this scar moved somehow, and so she was bleeding internally for 11 days. When her body couldn't produce more clotting factors, she just bled out. I rushed her to Unitas Hospital in Centurion. While getting there she fainted about 3 times. She went into casualties where the doc sort of stabilized her, but 10 min later she started bleeding again. They couldn't stop her from bleeding. At this time her gyno had arrived (Dr XXX). He was shocked and only seen one other occurrence of this before (a year before) and that lady didn't make it. So you could see it in his face that he didn't have hope for my wife. So he immediately called another gyno specialist to help. She got rushed to High care. Then this is where the drama started. Another lady Doctor (Dr YYY) was there and she also helped. So it's now 4 doctors and about 7 nurses trying to stop my wife from bleeding. From the report that I read later (I will attach), they were trying several drugs to try stop the bleeding, and the 3rd one they used was a drug called Novoseven. Dr YYY has read several articles overseas that this is the standard used overseas to stop bleeding. So they tried it also. We are now in about 3 hours of bleeding. They used a total of 12 units of blood (average body holds 8 units of blood). So now, Novoseven didn't work, so as a very last resort, she had to go for an emergency hysterectomy. At 29 year old, that's so sad, but it had to be done to save her life. Ok then after that, it was 5 days in ICU, but she alive and recovering quite well now, Thank GOD. After all was done, the doctors admitted to me that they didn't think she was going to make it. Dr YYY said had they been 5 min more, she would have died. Everyone there calls it a miracle!

NOW....

I get the bills. Discovery does not want to pay for the Novoseven (at a cost of exactly R46 472.27).
I phoned them, and 1st of all, at the time of the emergency, apparently the hospital did phone to ask if they could use it, Discovery wanted the nappi code, they didn't get back to them. Well because IT WAS AN EMERGENCY!
2nd, it seems it's a chronic medicine, and my wife is not registered to be using this chronic medicine. Well they used it because IT WAS AN EMERGENCY!
3rd, I just need a letter of motivation why the doc used the drug, I got one, I sent it, and Discovery's board has declined the use of the drug.

I really don't understand, I thought my medical was a 100% full hospital cover. Not a 100% full hospital cover minus some medicines. I really don't get it

Here is Dr YYY's letter

Mrs. S De Abreu was admitted via the emergency room with severe post-partum bleeding on the 11th of December 2011.
Medical history was that she delivered a healthy baby 2 weeks prior and then developed severe post partum bleeding.
On admission to the High Care Unit she was in extremis with hypovolemic and hemorrhagic shock.
Ongoing treatment by the Gynecologist Dr XXX did not manage to control the massive bleeding.

Despite ongoing resuscitation with clear fluids, packed reds cells, fresh frozen plasma and platelets she still continued to bleed profusely.
Cyclokapron and Vit K were administered with no apparent effect.
In a last effort to prevent an emergency hysterectomy in a 21** year old woman we administered recombinant activated factor VII (r FVII) Novo Seven to the patient.
There are overwhelming literature to support the early use of Novo Seven in uncontrollable post-partum bleeding.

This bleeding may have developed due to an acquired hemophilia A which may develop post-partum.
Acquired hemophilia A is an uncommon but potentially life-threatening hemorrhagic disorder caused by the development of autoantibodies directed against coagulation factor VIII.
The clinical picture is dominated by severe hemorrhage in the majority of patients, with an inhibitor-related mortality rate of up to 22%.
Vaginal bleeding is the predominant symptom if the inhibitor develops within a few days after delivery.

She was then taken to theatre for an emergency hysterectomy after all other measures to control the bleeding failed and the patient was at risk of dying from hemorrhagic shock.
An emergency hysterectomy was performed by Dr XXX and Dr ZZZ.
Although her clotting parameters were abnormal at this stage we managed to control the bleeding and she was transferred to the Intensive Care Unit post-operative.

The rest of her post-operative stay was uneventful and she developed no complications related to the massive transfusion she received.
She was discharged home one the 17th of December 2011.

The administration of NovoSeven contributed to the survival of this otherwise healthy young mother.

Please be so kind to consider reimbursement of the Novo Seven (rFVII).

Kind regards

Dr. YYY
Click to expand...
** I think Dr made a typo, my wife is 29 years old

Here is discovery's reply......

20 January 2012

Dear Mr De Abreu,

We have not confirmed benefits for funding of Novoseven

Thank you for sending us the details of Sandra’s planned procedure/treatment.
We sent Sandra’s request for funding for funding of Novoseven to our medical review team.
The review panel declined Sandra’s request for funding because the clinical information about Sandra’s condition does not meet our criteria for funding.

We make funding decisions based on our benefits

We recognise that Sandra’s doctor is in the best position to make medical decisions about her condition and treatment.
In declining the funding, we have not questioned the diagnosis or the treatment the doctor recommended.
As a healthcare funder, we decide about funding treatments to make sure the medical scheme can pay claims now and in the future.

We make consistent and fair funding decisions in the interest of all members of the Discovery Health Medical Scheme

Discovery Health’s role is to ensure members of the Discovery Health have access to quality healthcare in a way that remains affordable and sustainable.

Some of the ways we achieve this is in our plan and benefit design and the application of funding policies and clinical protocols.
These are developed using a rigorous, evidence-based decision-making process.
Using this process, helps us decide which procedures and treatment to completely exclude from cover and to develop funding policies for procedures and treatments that we have found to be clinically appropriate and cost-effective.

I hope this explains our funding decision and the process we follow to ensure we apply a funding policy that is fair to all our members.

Regards

DiscoveryCare
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A couple things I see wrong, 1st of all the procedure was not planned. Also "clinical information about Sandra’s condition does not meet our criteria for funding", so what condition does a person have to be in for them to fund it. I think near death is the ultimate condition.

So can someone advise me what to do next? Who do I speak to now? So I actually have a case here? Is discovery right?

Update1: 2012/01/30
http://tiny.cc/0kqzdw
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UD2: 2012/02/01
http://tiny.cc/clqzdw
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UD3: 2012/02/02
http://tiny.cc/plqzdw
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UD4: 2012/02/05
http://tiny.cc/1lqzdw
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UD5: 2012/02/07
http://tiny.cc/cmqzdw
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UD6: 2012/02/07
http://tiny.cc/l6qzdw
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UD7: 2012/02/09
http://tiny.cc/hsqzdw
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UD8: 2012/02/13
http://tiny.cc/rsqzdw
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UD9: 2012/02/14
http://tiny.cc/dtqzdw
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UD10: 2012/02/29
http://tiny.cc/9tqzdw
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UD11: 2012/03/08
http://tiny.cc/juqzdw
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UD12: 2012/03/13
http://tiny.cc/tuqzdw
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UD13: 2012/03/25
http://tiny.cc/4uqzdw
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UD14: 2012/03/29
http://tiny.cc/evqzdw
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UD15: 2012/05/08
http://tiny.cc/rvqzdw
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UD16: 2012/07/26
http://tiny.cc/ib21hw
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UD17: 2012/08/21
http://tiny.cc/lvmdjw
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FINAL Update18: 2012/10/05 - Discovery wins.........
http://tiny.cc/dcjplw
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The letter of response is very odd. They don't actually address the question of their refusal to pay for the use of Novoseven at all. There's just some woolly language about "rigorous, evidence-based decision-making process." Can't you question them on what exactly their decision making process entailed?
 
go see a lawyer. this was completely out of your hands. the doctors made the right decision at the time of their administering the drug to your wife. had they not done this she could be dead. there are moments when there is no time to contact medical aids to obtain permission and this is one of them.
 
I have replied to their e-mail, waiting to see for a reply. Though I'd get some advice in the mean time
 
2 things here:

1. This was either a Direct result of this doctor making a mistake while doing the C-Section
2. The medicine wasn't approved.

Now this leaves you with 2 choices:

1. The doctor takes responsibility and carries the cost of the medication
2. The medical aid pays it as it was a life and death emergency and since last year sometime all minimum prescribed benefits needs to be paid in full in a life and death situation.

I think the medical aid is declining it as they see it as a fault on the doctor's behalf and he needs to carry the cost. But they will never say it out aloud for obvious reasons.

Just my 2c's
 
Tell em to F off, as you say a hospital plan covers hospital stuff and medicine used was for an emergency. I could understand them not paying if she had to take a course of medicine but not for a life or death situation.

Tell them to pay and phone a lawyer in meantime. Dodgy fkers. You have to have cover yet they try and get out of paying for everything. You can also lodge a complaint with the ombudsman (spelling) and you should threaten to put them on hello peter or just go ahead and do it.
 
Did it state that your gap cover was used for the doctors/procedures? Couldn't they have used that to cover the cost of the medicine? I mean I thought the whole reason for gap cover was to cover you from the additional costs.

Good luck, glad your wife made a recovery.
 
Fudzy said:
Did it state that your gap cover was used for the doctors/procedures? Couldn't they have used that to cover the cost of the medicine? I mean I thought the whole reason for gap cover was to cover you from the additional costs.

Good luck, glad your wife made a recovery.
Click to expand...

I think a gap cover only cover if a doctor charges more than 100%. Not if they dont pay at all. But I will be trying them in anyway.
 
I don't think this is right of them to refuse payment. I got the same plan and got GAP cover via Forbes. It was clearly a emergency. With what company is your GAP cover, try asking them if the GAP will cover this? It's worth a shot.
 
beans100 said:
I don't think this is right of them to refuse payment. I got the same plan and got GAP cover via Forbes. It was clearly a emergency. With what company is your GAP cover, try asking them if the GAP will cover this? It's worth a shot.
Click to expand...

Also via Forbes. I am currently contacting them
 
Fudzy said:
How do you give someone hemophilia A?
Click to expand...

Did you read the doctor's letter in full?
She was then taken to theatre for an emergency hysterectomy after all other measures to control the bleeding failed and the patient was at risk of dying from hemorrhagic shock.
An emergency hysterectomy was performed by Dr JD Nel and Dr J Markram.
Although her clotting parameters were abnormal at this stage we managed to control the bleeding and she was transferred to the Intensive Care Unit post-operative.
Click to expand...

Again,

The doctor can write anything here as he is the only person who are in a position to make such a claim. That being said, there was no hemophilia A prior to the OP but as he mentions it developed post OP. And then after her hysterectomy it seemed to be fine again :confused:

Also there is mention by AntonioDA that the wound inside the womb moved ? :confused:

Pretty confusing don't you think?
 
Pitbull said:
Did you read the doctor's letter in full?


Again,

The doctor can write anything here as he is the only person who are in a position to make such a claim. That being said, there was no hemophilia A prior to the OP but as he mentions it developed post OP. And then after her hysterectomy it seemed to be fine again :confused:

Also there is mention by AntonioDA that the wound inside the womb moved ? :confused:

Pretty confusing don't you think?
Click to expand...

Doctor told me about the wound inside the womb. At the time, I was in sort of shock, so appologies for not quoting the Dr. correctly. Also, the wound is form when removing the plesenta. Its something the body does automatically, I think.
 
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Pitbull said:
2 things here:

1. This was either a Direct result of this doctor making a mistake while doing the C-Section
2. The medicine wasn't approved.

Now this leaves you with 2 choices:

1. The doctor takes responsibility and carries the cost of the medication
2. The medical aid pays it as it was a life and death emergency and since last year sometime all minimum prescribed benefits needs to be paid in full in a life and death situation.

I think the medical aid is declining it as they see it as a fault on the doctor's behalf and he needs to carry the cost. But they will never say it out aloud for obvious reasons.

Just my 2c's
Click to expand...

My wifes cut went open a few days after the C-section(2005). They told me before hand I was going to pay in R4500, after the incident, I received a bill for R0.00. The doctor carried the cost without me even having to ask them.
 
AntonioDA said:
dr Nel told me about the wound inside the womb. At the time, I was in sort of shock, so appologies for not quoting the Dr. correctly. Also, the wound is form when removing the plesenta. Its something the body does automatically, I think.
Click to expand...

Hi AntonioDA,

Not disputing your word or saying you are giving confusing info.

I'm saying that what the doctor is telling you and writing in his letter seems to be conflicting info from where I'm sitting. That being said, I'm no doctor and can't dispute what the doctor is saying. I just think that if he made a mistake he should own up and carry the cost. Your wife is alive and no foul done. But this now leaves you with R 50k debt I personally think you should not be liable for. This should be between the doctor and the medical aid.

I also think you should go see a lawyer and hear what they have to say.

Best outcome: Medical aid vs Doctor and you are released from all debt.
 
@ AntonioDA

Read through this:

http://www.saraa.co.za/images/PMB MARCH 2010.pdf

I think there was changes again in 2011. This should give you an idea of where you stand.

Summary on Emergency admissions:
PRESCRIBED MINIMUM BENEFIT SUMMARY JANUARY 2010
WHAT ARE PMB’S?
Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme
members have access to certain minimum health services, regardless of the benefit option they have
selected. The aim is to provide people with continuous care to improve their health and well-being and
to make healthcare more affordable.
PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the
costs related to the diagnosis, treatment and care of:
1. Any emergency condition
2. A limited set of 270 medical conditions
3. 26 chronic conditions
When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at
any other factors, such as how the injury or condition was contracted. This approach is called diagnosisbased.
Once the diagnosis has been made, the appropriate treatment and care is decided upon as well
as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s
rooms).
• ANY EMERGENCY CONDITION:
o An emergency medical condition means the sudden and, at the time, unexpected
onset of a health condition that requires immediate medical treatment and/or an
operation. If the treatment is not available, the emergency could result in weakened
bodily functions, serious and lasting damage to organs, limbs or other body parts, or
even death.
In an emergency it is not always possible to diagnose the condition before admitting
the patient for treatment. However, if doctors suspect that the patient suffers from a
condition that is covered by PMBs, the medical scheme has to approve treatment.
Schemes may request that the diagnosis be confirmed with supporting evidence
within a reasonable period of time.
Click to expand...
 
i think what this case is are "adhesions". i had this in february 2000 when i went for a hysterectomy. all went well with the operation. the first sign that something was amiss was when a week later i started bleeding vaginally. then i started getting abdominal pain which went on till i was reopened 6 weeks to the day. it was discovered that the scars from the hysterectomy had adhered to other parts internally which had pulled the small intestine out of where it was supposed to be.

i had a 5 and a half hour operation to fix this. i was in high care for 2 days. this has nothing to do with the doctor and it is rare that it happens. i went into theater at 5 in the afternoon and came out 10.30 that night after the surgeon had fixed everything.

i remember just slightly opening my eyes and my husband asking my gynae how long i would be in hospital and the doctor's response was that they wanted to get me through the night. i can clearly remember thinking well goodbye world. i was so high on all the medication they had me on and i swear they had me hooked up on every single machine in the hospital that went beep beep with oxygen as well.
 
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