Discovery Health claims paid from MSA

[TMoose]

Does anybody know why Discovery basically pays everything from your MSA? Last year I got glasses. They cost R2500. My plan supposedly has a R2000 benefit for glasses. Discovery paid something like R2200 from my MSA completely draining it for the rest of the year. After that they paid virtually nothing, not even prescribed medicine, because my MSA was depleted. I even ended up paying a few hundred rands for schedule 5 eye drops.

This year I went to the doctor with flu, once again they paid everything from my MSA. The doctor prescribed schedule 3 and above medicine, it also came out of my MSA. I had to go to the hospital last weekend with back pain, where they did x-rays and all of that also came from my MSA.

It is now almost depleted again, meaning that if I get sick again I'll end up paying hundreds of rands from my pocket like last year.

I pay them something like R1300 per month, and it feels like for that money I only get about R2000 worth of healthcare per year.

Why do they bother listing different benefits when all "benefit" you actually have is the MSA? Has anybody else experienced this type of thing? I just want to make sure I understand how they work before I start blowing my top.

As it feels now though, it's much better just to save the money each month and maybe get a cheap hospital plan. That way I'd be able to cover much, much more than what I'm getting at this stage.

 

[CathJ]

Depends on your specific plan, but on mine the only thing that doesn't come out of the MSA is if you're actually admitted to hospital.

 

[TMoose]

Depends on your specific plan, but on mine the only thing that doesn't come out of the MSA is if you're actually admitted to hospital.

But then isn't Discovery kinda a crappy medical aid? I'm on Essential Priority. My MSA for the year is something like R2k... that's nothing. And why put a R2k optical benefit there, if it just means that they pay R2k from your medical account anyway.

 

[ic]

AFAIK it depends on the ICD10 code that the service provider uses for a particular claim.

 

[[OUPA]MrNutz]

I'm exactly the same boat as you my friend..

I am currently on warfarin , so that means hopping in at PathCare each Monday for an INR session. @ R52.60 <---- not alot for one session but try adding that up for 6 months and that is over 60% of my Discovery MSA in sy **** in!

It's something the specialist wants , not that i want.

On top of that - specialist visits klap R500-R600 locally , so one more visit and my MSA is empty!

 

[avdp]

This is how understand it works.

Depending on the plan you are on, you should have Medical Savings Account (MSA), a Self Payment Gap (SPG) and your above threshold benefit (ATB).

Ie, if you are on Classic Compreheensive, two adults, 1 child, you have say a MSA of R12000, and a SPG of R1200.

All claims (except chronic) get paid from your MSA. Doctors visits, meds, tests, specs, pretty much everything.

Once your MSA is depleted, you enter your SPG. Here you pay for everything yourself, and still submit the claims to Discovery, so they can keep tally. Once they amount you have paid out yourself, equals the amount of your SPG, your above ATB kicks in again, where they pay for quite a lot of stuff again, ie doctors bills, meds over S2, etc.

The amounts available for ie spectacles, dental etc are your total allowed PA. Say for example you have depleted your MSA, and you have paid in you SPG, and are in ATB, and you havent used you spectacle allowance, if you then go and see the optometrist, it will be paid from your ATB.

But once again, it depends on your plan.

Thing to remember, if you get meds while still paying out of your MSA, all S2 and below add to your SPG. So if you get a S2 cough syrup, even though it gets paid from your MSA, it increases your SPG. So it is recommended you pay for those cash, so as not to increase your SPG.

Hope I got it right.

 

[Gothan]

I was with discovery, but luckily left them before they bankrupted me, now I am with fedhealth, and so far they are pretty decent, I have a huge MSA, plus a hefty threshold and stuff like glasses and so on, do not come out of your MSA (unless you go over the annual amount), only thing that basically deducts from your MSA is out of hospital doctor visits

 

[guest2013-1]

This is how understand it works.

Depending on the plan you are on, you should have Medical Savings Account (MSA), a Self Payment Gap (SPG) and your above threshold benefit (ATB).

Ie, if you are on Classic Compreheensive, two adults, 1 child, you have say a MSA of R12000, and a SPG of R1200.

All claims (except chronic) get paid from your MSA. Doctors visits, meds, tests, specs, pretty much everything.

Once your MSA is depleted, you enter your SPG. Here you pay for everything yourself, and still submit the claims to Discovery, so they can keep tally. Once they amount you have paid out yourself, equals the amount of your SPG, your above ATB kicks in again, where they pay for quite a lot of stuff again, ie doctors bills, meds over S2, etc.

The amounts available for ie spectacles, dental etc are your total allowed PA. Say for example you have depleted your MSA, and you have paid in you SPG, and are in ATB, and you havent used you spectacle allowance, if you then go and see the optometrist, it will be paid from your ATB.

But once again, it depends on your plan.

Thing to remember, if you get meds while still paying out of your MSA, all S2 and below add to your SPG. So if you get a S2 cough syrup, even though it gets paid from your MSA, it increases your SPG. So it is recommended you pay for those cash, so as not to increase your SPG.

Hope I got it right.

So what you're saying is getting a cheap hospital plan and taking the rest of the money and saving it for if/when you do get sick is better, because the medical aid bit only really kicks in once you've depleted not only the funds in your account (MSA) but the funds in your own pocket?

No wonder my friend paid like R3k and got diddly-squat. He was/is on chronic panic attack type meds and almost every year get bronchitis. By the time he does get sick there's no money at all to pay for a R100 bottle of meds... If he took that R3k and put it in a savings account he'd be able to pay his chronic medicine each month AND the doc/meds without batting an eyelid. Slap on a cheap hospital plan and if he's in an accident would be fairly covered for that.

And just because you have kids doesn't mean it necessatates (sp) a medical aid. a friend of mine, from prenatal to post and now is paying a crap load in expenses for medical stuff his aid didn't help cover. Actually drove him to get a personal loan to help cover it... insane.

I'd certainly save a decent portion that should go to the medical "aid" and then take care of my kids with that money. If that money doesn't deplete it's their varsity savings

 

[TMoose]

And here I was hoping that people would point and laugh at how I'm misunderstanding the situation. Meanwhile post after post seems to confirm that if you're on Discovery and you get seriously ill you're basically farked. One more doctors visit and my MSA will be depleted, which means I'll have to pay R4000+ from my own pocket PLUS fork out R1100+ to Discovery every month before I can reach the ATB. That's absolutely idiotic!

I pay them more than R14000 per year for medical cover. Somehow it seems like a bad deal if all I can get out of it is R2000 odd per year before I have to start paying for myself again.

I'm seriously going to have to consider leaving Discovery, even though I have a Discovery card and Vitality which I enjoy. Is there any way to keep the card / healthy food benefit / vitality part without being a member of the medical scheme part?

Frankly I'd rather have a comprehensive hospital plan at one of their competitors (cheaper anyway) and then have a separate savings account that I pay money into each month.

 

[Gaz{M}]

People need to remember that at the end of the day, you pay for all the medical services you require. Medical aid is not some kind of charity scheme where you pay in 50c and get out R2. It's pure insurance. That said, maybe there are cheaper options than Discovery.

 

[Syndyre]

And here I was hoping that people would point and laugh at how I'm misunderstanding the situation. Meanwhile post after post seems to confirm that if you're on Discovery and you get seriously ill you're basically farked. One more doctors visit and my MSA will be depleted, which means I'll have to pay R4000+ from my own pocket PLUS fork out R1100+ to Discovery every month before I can reach the ATB. That's absolutely idiotic!

I pay them more than R14000 per year for medical cover. Somehow it seems like a bad deal if all I can get out of it is R2000 odd per year before I have to start paying for myself again.

I'm seriously going to have to consider leaving Discovery, even though I have a Discovery card and Vitality which I enjoy. Is there any way to keep the card / healthy food benefit / vitality part without being a member of the medical scheme part?

Frankly I'd rather have a comprehensive hospital plan at one of their competitors (cheaper anyway) and then have a separate savings account that I pay money into each month.

You're basically paying for insurance I suppose. I pay about R1150 to Momentum for something similar, essentially all it covers is hospitalisation and chronic medicine, but at least if something serious happens you're fully covered.

 

[avdp]

I might be wrong?

We have been with Discovery for around 10 years, and there is very little they don't pay for, and I personally wouldnt change. However each to his own. The important thing is how you manage it. Personally wouldnt even consider looking at a hospital plan unless I have no other choice. They might be more expensive, but in my opinion they are good. And they settle our claims fast enough. Never had issues with them repaying if we paid and claimed back etc.

Daugther is on chronic asthma meds, and that would cost us a pretty penny if we didnt have it on chronic. Also, if you use their approved doctors (there are many), they pay a portion of it from MSA and a portion from your other benefits (basically ATB).

 

[guest2013-1]

I might be wrong?

We have been with Discovery for around 10 years, and there is very little they don't pay for, and I personally wouldnt change. However each to his own. The important thing is how you manage it. Personally wouldnt even consider looking at a hospital plan unless I have no other choice. They might be more expensive, but in my opinion they are good. And they settle our claims fast enough. Never had issues with them repaying if we paid and claimed back etc.

Daugther is on chronic asthma meds, and that would cost us a pretty penny if we didnt have it on chronic. Also, if you use their approved doctors (there are many), they pay a portion of it from MSA and a portion from your other benefits (basically ATB).

When you can't afford to push the cash upfront you're usually screwed. Insurance should be just that, insurance.

If my car gets stolen or written off, my insurance pays the value of the car er... insuring... I have the same vehicle and I'm not financially burdened and can get to work to earn money to pay the insurance.

Medical aid should be the same. If I claim R2000 out of the R14k I pay them every year for insurance then I shouldn't have to have depleted my MSA and pay for stuff myself before having them pay for stuff. Claim back or no claim back. I'd like to show my card and everything is taken care off without touching my MSA.

I always understood the MSA is there once they've stopped paying for stuff to top-off whatever you need or is out of medical aid type stuff. Sort of a savings account for when you need **** that's not covered. But anyway. Like you said, it works for you, and obviously you have the money lying around to pay for whatever you need and claim it back later.

I would love to see my car insurance make me pay for a new car and then get me to claim it back and taking 2-3 months to give me back the money for it.

insurance

Definition from the intarwebs:

Insurance is the transferance of risk. you have a risk..ex: you might get sick, you might die, etc. insurance TRANSFERS that risk (or rather the financial hardship created by it) from YOU to the insurance comany for a small monthly premium. So for example you MIGHT get sick and need R300,000 worth of medical services...So knowing you could never afford that, you purchase insurance...transferring the risk to the insurance company in exchange for your monthly premium.

What use is it to have insurance if the risk to shelve out the cash when you're sick yourself is still there? If I get sick and have to spend R15000 on medical expenses and then have to wait a few weeks/months before the medical paid me back I'd be broke. Unable to pay any other expenses, or as in my previous post, have to borrow the money somewhere to cover it.

INSURANCE people. Sure, it's not a scheme where you put in 50c and get out R2, but see above quote. Explains pretty much why you purchase it. I guess Discovery will argue they're a medical aid and not an insurance company :rollseyes:

 

[TMoose]

When you can't afford to push the cash upfront you're usually screwed. Insurance should be just that, insurance.

If my car gets stolen or written off, my insurance pays the value of the car er... insuring... I have the same vehicle and I'm not financially burdened and can get to work to earn money to pay the insurance.

Medical aid should be the same. If I claim R2000 out of the R14k I pay them every year for insurance then I shouldn't have to have depleted my MSA and pay for stuff myself before having them pay for stuff. Claim back or no claim back. I'd like to show my card and everything is taken care off without touching my MSA.

I always understood the MSA is there once they've stopped paying for stuff to top-off whatever you need or is out of medical aid type stuff. Sort of a savings account for when you need **** that's not covered. But anyway. Like you said, it works for you, and obviously you have the money lying around to pay for whatever you need and claim it back later.

I would love to see my car insurance make me pay for a new car and then get me to claim it back and taking 2-3 months to give me back the money for it.

insurance

Definition from the intarwebs:



What use is it to have insurance if the risk to shelve out the cash when you're sick yourself is still there? If I get sick and have to spend R15000 on medical expenses and then have to wait a few weeks/months before the medical paid me back I'd be broke. Unable to pay any other expenses, or as in my previous post, have to borrow the money somewhere to cover it.

INSURANCE people. Sure, it's not a scheme where you put in 50c and get out R2, but see above quote. Explains pretty much why you purchase it. I guess Discovery will argue they're a medical aid and not an insurance company :rollseyes:

+1. I was going to type something similar. Yes, it's health insurance, which means that some years I'm not going to claim anything and some years I'm supposed to be able to claim as much as it takes. In the olden days if I recall they used to tell you, you have R6000 for medicine, R10000 for doctors and whatever, and the Medical Savings Account nonsense didn't exist. They're supposed to balance the risk like any insurance company would.

EDIT:

I did this calculation quickly.

My premium is around R1388 including Vitality, so I think around R1288 just for the medical. Not 100% sure but it should be close enough.

That means I pay Discovery around R15456 per year for medical. They allocate around R2200 of that to my MSA, from which EVERYTHING gets paid. That means just one or two doctors visits a year could potentially deplete this, especially if expensive antibiotics get prescribed or as was the case recently I had to get x-rays taken. After that I enter the SPG where I need to pay for R4400 odd rand of stuff myself before Discovery start paying again.

Now, my ATB amount is R5000, so after I spent R4400 of my own money, Discovery will pay an additional R5000.

This means that to get R7200 worth of financial support from Discovery, I would have not only given them R15500 but also paid an additional R4400 from my pocket. In other words I pay R20k and they pay R7200. This seems like a tremendously bad deal to to me, unless I'm seriously misunderstanding the situation.

If I take a cheap hospital plan of say R600 and I save the R688 to an account I can buy myself R8256 of medical services and still be covered in case of accident or serious illness by the hospital plan. That means instead of paying R20k for R7200 of support I pay R15.5k and get R8k plus I'm covered for hospital.

 

[Serqet]

This is how understand it works.

Depending on the plan you are on, you should have Medical Savings Account (MSA), a Self Payment Gap (SPG) and your above threshold benefit (ATB).

Ie, if you are on Classic Compreheensive, two adults, 1 child, you have say a MSA of R12000, and a SPG of R1200.

All claims (except chronic) get paid from your MSA. Doctors visits, meds, tests, specs, pretty much everything.

Once your MSA is depleted, you enter your SPG. Here you pay for everything yourself, and still submit the claims to Discovery, so they can keep tally. Once they amount you have paid out yourself, equals the amount of your SPG, your above ATB kicks in again, where they pay for quite a lot of stuff again, ie doctors bills, meds over S2, etc.

The amounts available for ie spectacles, dental etc are your total allowed PA. Say for example you have depleted your MSA, and you have paid in you SPG, and are in ATB, and you havent used you spectacle allowance, if you then go and see the optometrist, it will be paid from your ATB.

But once again, it depends on your plan.

Thing to remember, if you get meds while still paying out of your MSA, all S2 and below add to your SPG. So if you get a S2 cough syrup, even though it gets paid from your MSA, it increases your SPG. So it is recommended you pay for those cash, so as not to increase your SPG.

Hope I got it right.

Yip you do have it right. I'm also on the same plan as the OP and that is how the call centre agent explained it to me when i phoned in. I got very sick at the beginning of the year and pretty much depleted my MSA within a few weeks. I then entered the SPG and faxed them through EVERYTHING i had paid for myself. They then gave me a number to sms to check what my SPG was. It was R0 and i phoned to confirm and she told me my ATB was now in place for the remainder of the year.

Discovery may be making a lot of money off us but i still feel out of all the medical aids they are one of the better ones. I was with Momentum and their plans were crap.

 

[Pitbull]

On my medical aid (CAMAF) I have a savings but everything just about is paid for by the medical plan. Only things taken from the savings is the difference in rates private doctors charge and the chemist levies. I keep on having 1000's left over every year and then carry to the next. I have so much savings, that if I could cash it in I could buy a nice car cash

Wonder wat's up with that ... But at least I know it is there the day I really need it

 

[Syndyre]

When you can't afford to push the cash upfront you're usually screwed. Insurance should be just that, insurance.

If my car gets stolen or written off, my insurance pays the value of the car er... insuring... I have the same vehicle and I'm not financially burdened and can get to work to earn money to pay the insurance

The other side of that argument is that your vehicle insurance doesn't pay for your car services, new tyres etc. Medical aid/insurance like this covers you mainly for serious illnesses which require hospitalisation. In that case they should cover it directly and you wouldn't need to claim it back.

 

[guest2013-1]

The other side of that argument is that your vehicle insurance doesn't pay for your car services, new tyres etc. Medical aid/insurance like this covers you mainly for serious illnesses which require hospitalisation. In that case they should cover it directly and you wouldn't need to claim it back.

That's why you have a warranty with the manufacturer, but like I said, you don't get insurance to have to pay the money out of your own pocket anyway. Insurance covers the financial burden risk you have and carries it over to the institution willing to insure you. It's a risk they take and you pay for them to do that.

If you'd like to argue with those details and fail to see the underlying point of the brevatity of my example with car insurance then fine. Go play in your fantasy corner over there and moan about how you don't have enough money to eat because one or more family members got sick and you suddenly had to fork out thousands upon thousands of rands for medical bills that should have been covered by the medical aid you had in the first place.

Apologies if that sounded like a personal attack. But people failing to comprehend what and why I used certain examples missing the point entirely and then finding they have a valid point to argue is just plain idjit-mindedness (which is an official sickness and can't be cured)

 

[Serqet]

I think we all realise though that medical aid/health insurance in this country is nowhere near the level we require, nor is it what you receive overseas. Government needs to step in and take hold of the situation.

 

[CathJ]

EDIT:

I did this calculation quickly.

My premium is around R1388 including Vitality, so I think around R1288 just for the medical. Not 100% sure but it should be close enough.

That means I pay Discovery around R15456 per year for medical. They allocate around R2200 of that to my MSA, from which EVERYTHING gets paid. That means just one or two doctors visits a year could potentially deplete this, especially if expensive antibiotics get prescribed or as was the case recently I had to get x-rays taken. After that I enter the SPG where I need to pay for R4400 odd rand of stuff myself before Discovery start paying again.

Now, my ATB amount is R5000, so after I spent R4400 of my own money, Discovery will pay an additional R5000.

This means that to get R7200 worth of financial support from Discovery, I would have not only given them R15500 but also paid an additional R4400 from my pocket. In other words I pay R20k and they pay R7200. This seems like a tremendously bad deal to to me, unless I'm seriously misunderstanding the situation.

If I take a cheap hospital plan of say R600 and I save the R688 to an account I can buy myself R8256 of medical services and still be covered in case of accident or serious illness by the hospital plan. That means instead of paying R20k for R7200 of support I pay R15.5k and get R8k plus I'm covered for hospital.

Yep, exactly. That's why I'm on Coastal Core - I'll pay for all my day to day stuff myself, they just have to pay if I need to be hospitalised (since that can be darn expensive, I'd prefer to not have to pay for it myself - or find that I can't afford to pay for it).

I long for the old days where everything was included, up to a limit, but I guess that if they did it these days it'd be so expensive that it still wouldn't be a viable option.