LISTEN | Discovery Health claims error: Members may owe thousands after miscalculations
Questions remain over whether Discovery Health has any legal standing to demand money from medical aid members whose claims were incorrectly paid because of a system error.
The scheme says it's discovered that the glitch caused claims for over-the-counter drugs and prescription medication to be paid out of medical savings accounts at higher rates than allowed under certain plans.
The failure caused some members on the Executive, Comprehensive and Priority plans to reach the 'Above Threshold Benefit' earlier than expected.
The ATB is a safety net benefit which sees Discovery provide further day-to-day cover past the threshold.
" The scheme was miscalculating how much they were paying for certain categories of medications. They would pay 50% for high-cost, non-preferred medications, 75% for certain non-generic medications. The scheme paid for them all in full, which means that these people reached that threshold sooner than they should have. They should have still been paying out of their medical savings and their own pockets. This mistake went on for an entire year," explains consumer expert Wendy Knowler.
Discovery Health has told Newswatch that fewer than 0.6 per cent of the more than 2.5 million members are affected.
Consumer journalist Wendy Knowler says she and another medical aid expert have been inundated with queries from medical aid members who have been contacted to pay back the money.
" I'm told by Mark Hyman of MediCheck [which helps medical aid members with claims problems] that on average, from his cases, and he's got over 800 now. He says the average amount that people owe is R20 000. The highest he's seen is R68 000.
"The big question is, 'Why should we pay, if it was your mistake?’. Discovery Health is saying, 'Well, we have an obligation in terms of our rules and medical schemes act to protect the fund - it's everybody's fund'.
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“But I think they're missing the actual issue here. The public sentiment around is that you're losing the human picture of 8,700 people. They're going to have to pay this money back," added Knowler.
Discovery Health says the recoveries are being handled in line with the Medical Schemes Act, the rules of the Council for Medical Schemes, and its own scheme rules.
It says according to those rules, if the scheme pays out more than it is liable for on a claim, or pays a benefit a member is not entitled to, it is allowed to recover that overpayment.
Knowler says the medical schemes council has yet to respond to requests for comment.
" Even Mark Hyman hasn't got a definitive answer out of them in terms of: Did Discovery medical scheme contact you? Did they consult you? And is Discovery correct in saying that everything is above board, it complies with the act, et cetera?, because that is the big question."
Discovery Health has apologised for the error and says it is working with affected members to provide support where needed.
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