Discovery and it's hidden clauses are killing me

[Arthur]

Duh... They're companies, not charity.

Er, not quite as simple as that. Medical Aid schemes cannot and do not make profits in the usual sense, and surpluses belong to the members, not the medical aid scheme.

Unlike normal insurance companies, the contributions paid to Medical Aid Schemes do not belong to the company but to the members. You can check for yourself by downloading the financial statements of the medical aid scheme to which you belong.

So, denying benefits or claims cannot and does not in any way financially benefit the administrators of the scheme. The company running the medical scheme charges the members an administration fee and that is legally capped as a percentage of member's contributions. They make the same amount of money whether they pay your claim or not.

Discovery medical aid scheme has one of the lowest administration fees, so its members on average have more funds available for medical services.

Many medical aid scheme administrators also offer a range of add-on and supplementary products (like "medical savings accounts", lifestyle incentives, gap cover, etc) that are legally, financially and administratively separate and distinct from the pure medical scheme services. These additional products can be for profit, of course.

In Medical Aid Schemes, the money is owned by the members (ie you and me) and the company administering the scheme (eg Discovery Health) can only charge an administration fee which is legally capped. They cannot make more profit by reducing or denying claims. Rolling Alpha explains it nicely.

Medical Insurance is ordinary short-term insurance. The contributions/premiums are owned by the insurance company.

 

[bwana]

Discovery's coastal core here. My kid had four wisdom teeth removed by a maxillofacial in hospital under general - had to pay a R4500 co-payment but even that was covered by gap cover.

 

[ghostRgg]

Discovery's coastal core here. My kid had four wisdom teeth removed by a maxillofacial in hospital under general - had to pay a R4500 co-payment but even that was covered by gap cover.

Thanks that's what I am looking for, want to move to something not in the smart essential line.

 

[Kosmik]

Sorry been knocked out every time I took my meds, hopefully I can get back to doing some work tomorrow.

Another mess up is the Gap Cover system my family has me on. They will only cover me till age 26 (I am turning 26 in December) if I was studying.

It just ticks me off again, sure I'm not studying but trying to start up my business over the years, but am now "kicked" off the backup gap Cover.

On Monday my plan is to speak to the Dentist and see if he can get pre-authorization to get it done in hospital as a medical emergency, because it really is one.

Last mess up was when my one stomach ulcer started bleeding and I went to ER and got a 2 hour temporary bed, after suffering on the carpark pavement for hours 5 hours, quick medication and treatment, turned around and sent home due to the hospital keeping beds for Covid patients.

Got invoiced for everything since I wasn't "admitted" which is honestly another wtf move. They took 6 vials of blood, then I never heard back from what they did with it or any results.

Please! Can anybody recommend a somewhat decent medical aid scheme. This Discovery Smart Classic is useless.

You would have had the same issue with most other plans. Casualty is a known problem with medical aids and on other plans it would have come out of your savings.

Most gap plans do have casuslty cover now though, so try claiming from that. Regarding the 26 year old age limit, if you are a dependant, that's quite generous, normally it's less. If your folks can provr your dependency, it may be waived but otherwise, you need to get out on your own now.

Personally, I do not like medical aid gap covers, go with a proper gap cover, not a bundled one.

 

[LetsDance]

The 'savings' thing is your money anyway. Makes no sense to have a savings plan. Also, if you have to downgrade your plan for whatever reason, you will be liable for any claims you made that would have been paid out of that savings so you are stuck for the year on that plan. What destroyed real medical aid was the PMB that came into being with the AIDS crisis. After that, medical aids had to get really creative to create the illusion that you were getting something worthwhile.

 

[w1z4rd]

Can you not go to a state hospital to have it done ?

Yeah you can, and its free and almost no queues. They only pull teeth at a hospital, but you dont pay anything and they do a good job.

 

[GhostSixFour]

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.

My wife had an emergency c-section and my son had to spend close to a month in NICU. Good luck covering that out of whatever savings you can muster.

There was a family there, that had a similar line of thinking, their baby - at that point - had spent close to 3 months in NICU, I'd estimate that bill to be close to R2-2.5bar.

 

[maumau]

The 'savings' thing is your money anyway. Makes no sense to have a savings plan. Also, if you have to downgrade your plan for whatever reason, you will be liable for any claims you made that would have been paid out of that savings so you are stuck for the year on that plan. What destroyed real medical aid was the PMB that came into being with the AIDS crisis. After that, medical aids had to get really creative to create the illusion that you were getting something worthwhile.

THANK YOU!!! People argue when I say this.

 

[Darynv]

Sorry for your situation OP, this is the reason I would not use Discovery even if my company paid half my premiums. From experience, they are the best at avoiding paying where they can (most MA's do this, as mentioned, they are a business not a charity and not paying out, just like Short term insurance, only they can be messing with poeple's lives and fall into a slightly different class). Sometimes you need to call their bluff, remind them that they are bound to cover things that can affect your quality of life, perhaps also remind them that a problem like yours could lead to death, they are usually willing to pay when they are trying to avoid headlines like "Medical aid refuses to pay, kills father of 2" or a wrongful death lawsuit.

 

[Aghori]

Discovery Classic Comprehensive here... around R6300 per month. It covers almost everything that could possibly happen but it's a money sink...necessary because of my old and frail family members.

 

[GhostSixFour]

THANK YOU!!! People argue when I say this.

I used to think the same. But, I had a google and found ARV's aren't that expensive. Perhaps they came down in pricing, since the time this was introduced. My searching shows that they can be had for less than R150 a pop.

 

[Aghori]

I used to think the same. But, I had a google and found ARV's aren't that expensive. Perhaps they came down in pricing, since the time this was introduced. My searching shows that they can be had for less than R150 a pop.

Huh? It's available from R73-R98, depending on supplier.

 

[GhostSixFour]

Huh? It's available from R73-R98, depending on supplier.

Whats the question? R73 - R98 is less than R150 correct?

 

[Kosmik]

My wife had an emergency c-section and my son had to spend close to a month in NICU. Good luck covering that out of whatever savings you can muster.

There was a family there, that had a similar line of thinking, their baby - at that point - had spent close to 3 months in NICU, I'd estimate that bill to be close to R2-2.5bar.

Cost a bar in 2012, been there, done that , got the t-shirt (bill).

 

[Kosmik]

Discovery Classic Comprehensive here... around R6300 per month. It covers almost everything that could possibly happen but it's a money sink...necessary because of my old and frail family members.

Thats per member, its not affordable even for a small family.

 

[Drifter]

Medical Aids are a rip off as rule.

 

[Pineapple Smurf]

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...

Ouch
I know how you feel
Also had an abscess about 15 years ago.
I ignored it for as long as I could
I got jawlock and couldnt open my mouth at all
I lived on coffee and went through a pack of painkillers a day, 30 in total
Eventually went to a Oral Specialist and he took 1 look at me and said it is surgery time

Quoted me R30k right there
I said I am Pay as you Go so he sent me to government hospital
They had to go through my jaw from underneath to get to the tooth and extract it and the kak inside.
When I woke up next morning Doctors told me I was bloody lucky to be alive as if I had waited a day or more there would have been a good chance the abscess would have forced my breathing pipe shut.
That is how swollen my face and neck were.

Cost me R150 for the op and the 10 days recovery in hospital.

 

[RedViking]

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...

It is very clear in their plans. They don't cover dental, and if they do extremely limited. Same for other medical aids. Only their expensive plans cover it to some degree.


Government Hospital.

They will help you put your head through a wall.

 

[RedViking]

Medical Aids are a rip off as rule.

Or people just need to read their plans. Everything in Africa is a rip off.

 

[Pineapple Smurf]

It then took a further month before I could open my mouth again to get food inside.
Living on soup was boring as hell for that time