Discovery and it's hidden clauses are killing me

[ghostRgg]

Been in pain for two days now and finally went to the dentist, I have a severe abscess in my top jaw that is spreading and I flaming my whole left side of my face.

I was told I need one week of antibiotics to calm it down so they can actually operate. They need to do surgery and Discovery won't cover a cent.

Anything dental related even an emergency in hospital won't be covered and I need a maxofacial too.

Even just collecting my meds, Discovery refused to cover it.

I am on the Smart Essentials plan, I know it's cheap but how can I get declined for a nessisary in-hospital operarion?

They are asking R12k upfront then you pay for everything else too.

I need some advice because I am in the kind of pain that makes me want to put my head through a wall...

 

[zerocool2009]

Welcome to a medical aid! Its all about the money

 

[pinball wizard]

I doubt very much the clause was hidden.

I suspect the OP simply did not fully read and/or understand the benefits of the plan he's on when signing up for it.

 

[Ghost64]

They cover wisdom teeth removal, don’t see why this won’t be covered. Perhaps speak to your doc/surgeon to motivate it from their side.

 

[TofuMofu]

I'm on the Smart Classic plan and they paid for a big portion of my in-hospital implant. Are you sure it's at a network hospital?

https://www.discovery.co.za/wcm/discoverycoza/assets/medical-aid/benefit-information/2021/dhms-hospital-network-list-2021.pdf

Also get a quote from the dentist or whoever is doing the op with the codes and phone Discovery for authorization.

 

[ghostRgg]

I doubt very much the clause was hidden.

I suspect the OP simply did not fully read and/or understand the benefits of the plan he's on when signing up for it.

Yup its all my fault for not fully checking.

 

[ghostRgg]

 

[Nemesys]

On your plan it really depend on what procedure your doctor is going to do. Make sure that the procedure codes and ICD 10 codes are correct and ask tou doctor to schedule the op in a Day surgery network. The upfront payment will however be R7050

Severe dental and oral surgery in hospital The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with no upfront payment and no overall limit. Certain procedures are covered in our Day Surgery Network. This benefit is subject to authorisation and the Scheme’s Rules. Other dental treatment in hospital on the Classic Smart Plan You need to pay a portion of your hospital or day clinic account upfront for dental admissions. This amount varies, depending on your age and the place of treatment. We pay the balance of the hospital account from your Hospital Benefit, up to 100% of the Discovery Health Rate (DHR). We pay the related accounts, which include the dental surgeon’s account, from your Hospital Benefit, up to 100% of the Discovery Health Rate (DHR). We pay anaesthetists up to 200% of the Discovery Health Rate (DHR). For members 13 years and older, you must pay for routine conservative dentistry, such as preventive treatment, simple fillings and root canal treatment. Upfront payment for dental admissions:
Hospital account Day clinic account Members 13 years and older: R7 050

 

[AstroTurf]

All the medical aids, dental and optometry support is terrible.

Guessing hearing will be the same.

 

[zerocool2009]

All the medical aids, dental and optometry support is terrible.

Guessing hearing will be the same.

It comes from “savings”

 

[d0b33]

I'm on the cheapest plan. It costs over 4k a month for a small family. It's essentially useless for day to day. The affordability scale is a joke too, if you make more than 13k you can expect to pay half that salary for a family.

 

["D"]

I am in the kind of pain that makes me want to put my head through a wall...

As a matter of urgency, get painkillers first. (By the way, alcohol helps the efficacy of codeine. But it probably isn't necessary nor ideal.)
In addition to the antibiotics, a regular high dose of Vit D can bring down inflammation. (By the way, magnesium helps Vit D absorption and vice versa.)
It also helps if you get the blood pumping (cardio exercises) especially because abscesses are blocked in.
It could also be handy to supplement with NAC because it is antifungal, antimicrobial, antibacterial, and it boosts glutathione levels quickly, which could bring down inflammation...

 

[AstroTurf]

It comes from “savings”

yea each one has their own special word for "your problem not mine"

 

[Ghost64]

As a matter of urgency, get painkillers first. (By the way, alcohol helps the efficacy of codeine. But it probably isn't necessary nor ideal.)
In addition to the antibiotics, a regular high dose of Vit D can bring down inflammation. (By the way, magnesium helps Vit D absorption and vice versa.)
It also helps if you get the blood pumping (cardio exercises) especially because abscesses are blocked in.
It could also be handy to supplement with NAC because it is antifungal, antimicrobial, antibacterial, and it boosts glutathione levels quickly, which could bring down inflammation...

What’s NAC?

 

[zerocool2009]

I have downgraded to a hospital plan only (building my own savings up). It doesnt help one gets sick, going to the dr, get meds and its all from Savings. Same with teeth.

 

[AstroTurf]

side note,

Our son had an abscess, they tried puling the tooth and could not (he refused to open his mouth after the clamp slipped half way through pulling), last week we had to fork out for an anaesthesiologist to get the tooth out the rest of the way as the medical had already put him under in the past 12 months.

Poor guy walked around for a week with a half pulled tooth, at least the antibiotics got the swelling down.

 

["D"]

What’s NAC?

Anti-hangover supplement.

It's basically cysteine. (In bodily processes it is a direct precursor to glutathione formation.)

Long name: N-acetyl-L-cysteine.
(It's the main ingredient that makes ACC200 tablets so effective.)

 

[Sapphiron]

Something I discussed with family and friends at one point, is that even for those who had medical operations and claims, it would have been significantly better for them to take their medical aid contributions over the year and invested them into conservative investments with relatively short periods to release the money (30 days).

The only issue is getting the first ~R200k for that initial safety net.

 

[LostGoat]

The essential plan has a lot of exclusions.
Look on page 37: https://www.discovery.co.za/wcm/dis...alth-medical-scheme-smart-plan-guide-2021.pdf

 

[Stonemason]

As a matter of urgency, get painkillers first. (By the way, alcohol helps the efficacy of codeine. But it probably isn't necessary nor ideal.)
In addition to the antibiotics, a regular high dose of Vit D can bring down inflammation. (By the way, magnesium helps Vit D absorption and vice versa.)
It also helps if you get the blood pumping (cardio exercises) especially because abscesses are blocked in.
It could also be handy to supplement with NAC because it is antifungal, antimicrobial, antibacterial, and it boosts glutathione levels quickly, which could bring down inflammation...

Careful about giving alternative advice. A serious dental abscess can and will kill a person in a very short period if left untreated. It is best if the OP makes a plan to urgently get hold of the antibiotics and follow his dentist's orders to the letter. This is not something one can play with.