Discovery Health Medical Scheme has paid more than R2 billion towards the medical treatment of its members who were injured in vehicle accidents since 2006.
The fund has also never refused to pay for treatment, and has not forced any member to submit a claim to the Road Accident Fund (RAF) following an accident. But if the members do submit a claim to the RAF and receives a payout, Discovery expects the member to refund the medical expenses incurred.
This has been the core message of Dr Jonathan Broomberg (pictured), CEO of Discovery Health, at media conference in Johannesburg in response to several claims made by Johannesburg personal injury attorneys Ronald and Darren Bobroff of law firm Ronald Bobroff and Partners (RBP).
The father and son team recently sent a 24-page document entitled A shocking discovery for Discovery Medical Aid members to virtually every attorney and advocate in South Africa.
Read Bobroff shouts “vendetta”
In the document they allege that Discovery Health does not cover its members who are injured in motor vehicle accidents, and that Discovery threatens to withhold payment if injured members do not undertake to lodge claims with the RAF and to refund Discovery for the medical expenses it has paid.
Broomberg strongly denied these allegations. He then highlighted Discovery’s policies and procedures when a member is injured in a vehicle accident. “Discovery members are fully covered for injuries or any other healthcare claims that result from a motor vehicle or any other injury.”
He said claims are settled as soon as they are received, typically within three to five days.
Broomberg emphasised that Discovery Health does not force its members to submit claims against the RAF, but that if members decide to do so and receive a payout, the members are obliged to refund Discovery for medical expenses incurred.
If a member choses not to claim from the RAF then Discovery Health would not recover any money. This, Broomberg said, had been the position of Discovery Health all along.
Bobroff has questioned this and referred to Discovery Health’s Rule 15,6 which compels a member to “be obliged to take all steps which are necessary to timeously submit to the RAF a claim for compensation for the costs of any healthcare services performed and which in the future may be necessitated in connection with such injury.”
Broomberg’s explanation was: “This rule dates from 2000 and originated in the Council for Medical Schemes (CMS) Model Rules for all schemes. Discovery Health has never enforced this rule.” He also noted that this approach was “consistent with every other medical aid in the market.”
The Bellon matter
This public spat between Discovery Health and Bobroff follows a complaint regarding the refunding of medical expenses Bobroff lodged against Discovery in 2011 on behalf of his client Mark Bellon.
To date, this has been the only official complaint Discovery has received regarding the refunding of such expenses from RAF payouts.
Bellon, formerly a charted accountant, was severely injured in a motor vehicle accident in 2006. He and his wife Jody, both former Discovery Health employees, alleged that Discovery demanded an undertaking shortly after the accident and whilst Bellon was in an intensive care ward that he should submit a claim to the RAF and if successful, refund to Discovery the payout covering medical expenses.
Bellon failed to repay Discovery Health fifteen months after the accident. Bobroff’s law firm RBP also gave an undertaking to refund Discovery Health, but also reneged, following which Discovery cancelled Bellon’s membership to the scheme.
Bobroff then hauled Discovery before the CMS, but in October 2011 the CMS handed down a comprehensive ruling in which they found in favour of Discovery.
Bellon is appealing this ruling.
In response, Bobroff stated that the CMS “acted improperly and irregularly”, and despite giving an undertaking to commence with an investigation as to whether Discovery was complying with the Medical Schemes Act. This investigation never took place.
R2 billion paid out
In countering the Bobroffs’ allegations, Broomberg said that since the time of Bellon’s accident, Discovery had paid out around R2 billion to over 25 000 members who has been involved in motor vehicle accidents.
During 2013 alone Discovery had paid R233 million in claims in respect of 3 876 motor vehicle accidents. Each claim cost Discovery on average R60 268.
RAF stripping
Broomberg also said rapacious attorneys who have been charging unlawful fees when claiming on behalf of clients, has a negative effect on members, Discovery Health and the RAF.
This follows several cases in which the North and South Gauteng High courts, the Supreme Court of Appeal and the Constitutional Court have found RBP’s common law contingency fee agreements to be unlawful and ordered the firm to repay millions of Rands to the respective clients.
“We also believe that we have a duty to defend the integrity of the broader structures of our society, in this case the RAF,” Broomberg said.
RBP has consistently argued that although its common law contingency fee agreements charged more than was allowed for in the Contingency Fee Act, it was within the rules set out by the Law Society of the Northern Provinces.
Bobroff also said in response to Discovery’s media briefing: “We also find Discovery’s frantic efforts at seeking to, yet again, conceal the truth and deflect attention from its unlawful fraudulent and immoral conduct by attacking us, entirely understandable, if amusing.”
