Discovery scheme torment for Joburg woman

[ryu]

Discovery scheme torment for Joburg woman

For almost two months Beverley Smith has been in agony, and has now lost the use of her leg while her medical scheme continued to deny authorisation for a spinal operation.

A Johannesburg woman has spent more than a month in excruciating pain, waiting for spinal surgery which her medical scheme has refused to authorise until now.

Beverley Smith (58) was on holiday with her husband Basil when she started experiencing pain in her left leg, hip and knee. This quickly progressed to partial paralysis of her leg.

“Bev is a strong-headed woman, and I suppose she might have misinterpreted the initial symptoms as just a pulled back muscle. The severe pain and partial paralysis developed within a day or two, and I assume the painkillers and anti-inflammatory medication which she was taking probably “masked” the problem” said her husband Basil.

However, the real nightmare for Beverley, who is a Discovery Health Medical Scheme member, began when Discovery refused to authorise surgery, despite letters from her specialist doctors, citing the importance of the surgery.

All treatment refused

Basil said that initially Discovery refused any treatment. They claimed that she did not qualify because she had not undergone six months' ‘conservative treatment’, in compliance with the SA Spine Society Guidelines.

According to a report in The Star, Beverley’s neurosurgeon, Dr Percy Miller and an orthopaedic surgeon had both written letters of motivation to Discovery, explaining her urgent need for an interspinosal stabiliser and fixator – known as a U-device – to be inserted surgically in her spine, and a decompression. But Discovery refused the authorisation.

This went on for weeks and by the middle of July, Beverley’s condition had worsened to the point where she was mostly bed-ridden and had lost the use of her left leg. She was also in constant , agonising pain.

Following the report in The Star and subsequent media coverage however, it appears that Discovery has overturned its decision.

However, the Smiths remain in the dark about where to go from here, as it appears Discovery is not keeping them in the loop.

“Discovery is not communicating directly with me. All the communication is sketchy, and in my opinion they are not 100% specific, other than that they still claim that I am not actually covered for the specific condition, and that it is not a PMB [Prescribed Minimum Benefits] condition."

“As far as I know they have contacted one of our doctors to advise that he may only operate to remove the “obstruction” but not insert the interspinal device – but he apparently declined to do half a job.”

What Discovery says

In a statement received from Discovery, Dr Jonathan Broomberg (CEO Discovery Health Medical Scheme) said that the scheme “provides cover for spinal surgery according to the benefits of a member’s specific plan type. As spinal surgery carries significant risks and should only be done where appropriate, these benefits are also subject to defined clinical guidelines, which are developed in consultation with leading spinal surgeons in South Africa. This ensures that the guidelines take into account the latest available published evidence and the best available local and international expertise, including the risks and benefits for patients from this type of surgery.”

With regard to the Smith’s case he said, “The initial request for funding for the spinal surgery using the interspinous device was declined, as Mrs Smith did not meet the criteria as per the Spine Society Guidelines. This does not imply that any spinal surgery was declined, but only the use of this specific device.

Subsequently Mrs Smith consulted a new doctor to obtain a second opinion, and late last week, Discovery Health received further detailed clinical information. This updated information was submitted to the SA Spine Society, which confirmed that the patient will benefit from spinal surgery in terms of the Society Guidelines.

This was not the case based on the prior information. Based on this updated information, we have indicated to the member that the spinal surgery will be authorised immediately.”

‘Not good enough’

However, Basil is not satisfied with this response, and while he is pleased that the surgery has finally been approved, he says he has still not personally been informed, despite being the one in constant correspondence with Discovery.

“I heard from Voyu from The Star, who contacted me to say that she had spoken with Dr Laric, who confirmed that Discovery has approved the full operation. However, I am still waiting for them to advise me directly.

“Why should I get this detail from a third party? I am therefore declining to operate until they contact me personally and in writing. They need to explain why they are now approving the full procedure, and also why, besides the conservative treatment, they declined it in the first place.

“I refuse to call them – they need to call me.”

Disgusting and not the first time i have heard of this type of situation from discovery.
which is why i will never join them.

Link: News24

 

[Ancalagon]

This is business as usual. Discovery is not the only scheme who will do such things.

Disclaimer: have been a discovery member for years, never really had any problems, but then I do not believe there is a single scheme out there that will not try to screw its customers over. Profit is the number one motive, not health care.

 

[Tinuva]

This is business as usual. Discovery is not the only scheme who will do such things.

Disclaimer: have been a discovery member for years, never really had any problems, but then I do not believe there is a single scheme out there that will not try to screw its customers over. Profit is the number one motive, not health care.

I am in the same boat, haven't had problems with them yet....

But I can help and wonder...what will happen the day I do need them, and then they pull a stunt like this. Doesn't instill much confidence for me at all.

 

[xrapidx]

“I refuse to call them – they need to call me.” - so while he's stubborn his wife suffers?

 

[Wall]

“I refuse to call them – they need to call me.” - so while he's stubborn his wife suffers?

Was thinking exactly the same.

 

[googoodoll]

Does her plan option actually cover spinal surgery?

My cheapie Discovery plan doesn't but I knew that before I signed up

 

[xrapidx]

Does her plan option actually cover spinal surgery?

My cheapie Discovery plan doesn't but I knew that before I signed up

Where would you check that?

 

[Fudzy]

In a statement received from Discovery, Dr Jonathan Broomberg (CEO Discovery Health Medical Scheme) said that the scheme “provides cover for spinal surgery according to the benefits of a member’s specific plan type. As spinal surgery carries significant risks and should only be done where appropriate, these benefits are also subject to defined clinical guidelines, which are developed in consultation with leading spinal surgeons in South Africa. This ensures that the guidelines take into account the latest available published evidence and the best available local and international expertise, including the risks and benefits for patients from this type of surgery.”

Sounds fair, I've heard from both doctors and brokers that the cheaper budget plans are responsible for the escalating fees as these policy holders use and abuse more than what they pay in and are entitled to. They either pull the option for tiered pricing structures or lessen the expenses incurred by those on the cheaper policies.

 

[Fudzy]

Where would you check that?

https://www.discovery.co.za/portal/individual/plans-overview

EDIT: URL updated to make it easier.

 

[ISP cash cow]

Where would you check that?

Discovery give you a whole breakdown of what your plan covers and what it does not cover. Even on their website you can login and list your procedure and they will tell you if you are covered or not and if yes to how much you are covered.

I have never had an issue with Discovery health.

 

[ryu]

This is business as usual. Discovery is not the only scheme who will do such things.

Disclaimer: have been a discovery member for years, never really had any problems, but then I do not believe there is a single scheme out there that will not try to screw its customers over. Profit is the number one motive, not health care.

i see your point but i will still complain at the least if this happened to me. we shouldnt take these things lightly just because all medical schemes do it. we make a fuss so they will think twice the next time they try to screw us over.

i think if people complain and get their story published it will create enough attention so other members can see what they are doing and cancel their membership if they feel strongly about it, this means discovery will loose money and will actually try to rectify the situation and possible stop it from happening in the future.

just my 2c but yeah bottom line is we shouldnt just sit on hands and take this non sense.

oh also wondering wtf is up with the husband ? i would let them pay asap and then complain afterwards about the service instead of making his wife wait in pain.

 

[xrapidx]

https://www.discovery.co.za/portal/individual/plans-overview

EDIT: URL updated to make it easier.

Discovery give you a whole breakdown of what your plan covers and what it does not cover. Even on their website you can login and list your procedure and they will tell you if you are covered or not and if yes to how much you are covered.

I have never had an issue with Discovery health.

Will need to have a closer look. I just assumed everything serious would be covered.

 

[Wyzak]

All Discovery members should send an email to healthinfo@discovery.co.za and demand an explanation. The very least that Discovery could do is to send an email to it's members and inform them of the situation and why they are doing what they are doing, and how to prevent it from happening to you.

 

[Nerfherder]

“I refuse to call them – they need to call me.” - so while he's stubborn his wife suffers?

Thats why you have to read the entire article.... you always see little comments that show the other side of the story.


Discovery is full of rubbish but when you consider that they have to deal with people like this you understand why.

 

[googoodoll]

Where would you check that?

If you log into the Discovery website you can check your benefits. You can also email them and they reply quite quickly confirming your benefits. Or you can phone them. Or you can check the papers you signed and filed when you signed up.

https://www.discovery.co.za/discovery_za/web/pdfs/health/disc_health_plan_comparison_eng_2012.pdf

 

[Fudzy]

All Discovery members should send an email to healthinfo@discovery.co.za and demand an explanation. The very least that Discovery could do is to send an email to it's members and inform them of the situation and why they are doing what they are doing, and how to prevent it from happening to you.

Not sure if serious?

 

[Wyzak]

Not sure if serious?

Most certainly serious. If Discovery did nothing wrong they should provide an explanation of the situation and why they took the action they took. By remaining deadly quiet they are looking more and more like the bad guys that we often hear they are.

In my experience you need to have a doctors degree or tons and tons of free time to even begin to grasp which conditions are not covered by the medical schemes.

 

[Fudzy]

Most certainly serious. If Discovery did nothing wrong they should provide an explanation of the situation and why they took the action they took. By remaining deadly quiet they are looking more and more like the bad guys that we often hear they are.

In my experience you need to have a doctors degree or tons and tons of free time to even begin to grasp which conditions are not covered by the medical schemes.

Well that's why I asked, there are probably a thousand different cases that aren't covered, the mail would have to be quite a comprehensive list.

 

[googoodoll]

Most certainly serious. If Discovery did nothing wrong they should provide an explanation of the situation and why they took the action they took. By remaining deadly quiet they are looking more and more like the bad guys that we often hear they are.

In my experience you need to have a doctors degree or tons and tons of free time to even begin to grasp which conditions are not covered by the medical schemes.

So they can respond to emails instead of authorising procedures....

 

[Wyzak]

So they can respond to emails instead of authorising procedures....

It's not like the company only has one employee.... Their PR team should draft a leader have it checked by a doctor or two and then send it out to their customers. Hectic...