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  1. #1
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    Default Does your medical aid cover what you think it covers?

    Unlike the short term industry, you may migrate once a year up or down or even move immediately in emergency situations

    Now just never be without medical, thats rule one. But we think the comprehensive plans covers everything. Think again.

    Get yourself a broker to get whoever will look after you the best. Do not think the "biggest" brand is the best.

    Some therapies are not covered at all by most [because of cost] and some does cover most.

    The sad thing is the cost associated with decent cover
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  2. #2
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    Default Re: Does your medical aid cover what you think it covers?

    The most important thing is to take time to read the scheme details and carefully compare the various plans offered. Do not solely rely on a broker, do your own research as well.

    Medical aid plans will most likely be a compromise, no plan is a perfect fit. Also make sure that you don't end up paying for stuff you will not use, those extra's cost you money.
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  4. #3
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    Default Re: Does your medical aid cover what you think it covers?

    It would be nice if they just paid for the stuff they are contracted to pay without always trying to weasel out of it or put up a fight.

    I have a friend in the industry, that it site CEO of a rival company that is busy fighting with Discovery for a claim for one of his employees that was covered under their group scheme with Discovery.

    He is very well aware of the legalities and obligations and knows he will win the fight, eventually, but he is a lawyer by training and works in the industry and has the backing of a full legal team. Pity the poor pleb who just gets invoices refused and does not know how to fight these guys.

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  6. #4
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    Default Re: Does your medical aid cover what you think it covers?

    Check your cancer (oncology) benefits. If it states PMB, you are only covered if there is a good chance that you will get healed.
    Louis Farrell

  7. #5
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by OettingerTDi View Post
    The most important thing is to take time to read the scheme details and carefully compare the various plans offered. Do not solely rely on a broker, do your own research as well.

    Medical aid plans will most likely be a compromise, no plan is a perfect fit. Also make sure that you don't end up paying for stuff you will not use, those extra's cost you money.

    The problem isn't reading, the problem is understanding, you must understand the plan you sign up for.
    "The man who does not read has no advantage over the man who cannot read" - Not Mark Twain

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  9. #6
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by stephenplumb View Post
    It would be nice if they just paid for the stuff they are contracted to pay without always trying to weasel out of it or put up a fight.

    I have a friend in the industry, that it site CEO of a rival company that is busy fighting with Discovery for a claim for one of his employees that was covered under their group scheme with Discovery.

    He is very well aware of the legalities and obligations and knows he will win the fight, eventually, but he is a lawyer by training and works in the industry and has the backing of a full legal team. Pity the poor pleb who just gets invoices refused and does not know how to fight these guys.
    Yep. Dioscovery is very good at doing a pre-approval and then not paying the service provider when the bill arrives...........

    Sitting with a R5k debt now: procedure that was pre-approved but suddenly wasn't approved according to PSB and now I'm in debt to the orthodontist......
    Jakes Louw
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  11. #7
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    Default Re: Does your medical aid cover what you think it covers?

    We were looking at going onto a "comprehensive" plan as my wife has an eye condition that requires regular specialist visits, and my son has therapy needs.
    The red tape and complete vagueness that you get from the medical aid companies about what is and isn't covered and limits / caps / exclusions....
    Its impossible for anyone to navigate, even our consultant was not able to give us clear answers from what the medical aid was saying.
    We ended up staying on our classic cover.
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  13. #8
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by jelo View Post
    Yep. Dioscovery is very good at doing a pre-approval and then not paying the service provider when the bill arrives...........

    Sitting with a R5k debt now: procedure that was pre-approved but suddenly wasn't approved according to PSB and now I'm in debt to the orthodontist......
    someone have to pay for discovery bank loss.

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  15. #9
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    Default Re: Does your medical aid cover what you think it covers?

    What riles my broker more than anything, is that when Discovery has a get together (marketing event) for the brokers, he said they will trumpet gyms, airfares, shopping discounts etc. Basically they talk about everything but medical insurance which is the product the customer is actually buying.

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  17. #10
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by LouisF View Post
    Check your cancer (oncology) benefits. If it states PMB, you are only covered if there is a good chance that you will get healed.
    I must say that when my wife was diagnosed with cancer in 2009, Discovery covered the related expenses in a big way.
    Johan Swanepoel

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  18. #11
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    Default Re: Does your medical aid cover what you think it covers?

    What gets me is when the costs / procedures are pre-approved / authorized whatever - then afterwards (about a year later) you will get a bill threatening legal action to collect Rejected Medical Aid claims.
    By then you cannot any longer claim on GAP cover - past the deadline.
    Then if you look up on your member monthly claims statements you will find a code indicated that a negotiated settlement was reached on the charges levied and that medaid paid at those rates.
    It sometimes even states "Patient not liable".
    Other issues are path and blood test labs not being paid since they did not received the required or authorized or requested forms from someone (??) usually the lab itself or the hospital ?
    These things come to your attention after the deadlines for claiming have passed, so no chance to claim on GAP - which in any case only covers shortfalls on charges (differences) between medaid rates and charged rates. If the amount was rejected by medaid anyway - then no cover.

    Now I am not speaking of Discovery or any other particular medaid - this seems to be the norm.
    We have been on different plans over the years - no different.

    To be fair \i must say that over 95% of substantial costs HAVE been covered and paid, but usually after a lot of hastle, correspondence and follow up.
    Not something I enjoy doing in my so called golden years.

    OK, rant over - but someone else started it.
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  20. #12
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    Default Re: Does your medical aid cover what you think it covers?

    The individual/specialist doctors and the front office staff don't help either.

    "Don't worry sir, everything is covered. We process everything on your behalf'

    Which they do, until it isn't covered, or partially covered, and then its suddenly your problem.

    Or, yes, our rates are covered, but the anesthetic is a different issue, and you need to settle with them. Um...I had no interaction with "them", you did and you said it was covered.
    Last edited by Quiksilver; 2021/09/20 at 11:15 AM.
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  22. #13
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    Default Re: Does your medical aid cover what you think it covers?

    Well I for one was totally astounded. With my recent Covid ICU and externals my bill was 1.5 bar. EVERYTHING covered and paid. I was sure we were in for at least 100k. Not one cent needed.
    I know every case is different.

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  24. #14
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by stephenplumb View Post
    It would be nice if they just paid for the stuff they are contracted to pay without always trying to weasel out of it or put up a fight.

    I have a friend in the industry, that it site CEO of a rival company that is busy fighting with Discovery for a claim for one of his employees that was covered under their group scheme with Discovery.

    He is very well aware of the legalities and obligations and knows he will win the fight, eventually, but he is a lawyer by training and works in the industry and has the backing of a full legal team. Pity the poor pleb who just gets invoices refused and does not know how to fight these guys.
    Discovery stopped rehab for my wife after her stroke. 432 emails , 18 months and the CMS and eventually they lost.
    Now made it almost impossible to start again as they refuse to change original authorisation number so the work from homes just click "no".....
    There is no task too simple for some people to complicate !



    Ford Figo 2016

  25. #15
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by jelo View Post
    Yep. Dioscovery is very good at doing a pre-approval and then not paying the service provider when the bill arrives...........

    Sitting with a R5k debt now: procedure that was pre-approved but suddenly wasn't approved according to PSB and now I'm in debt to the orthodontist......
    Call recorder is a must on your phone. Helped me a few times.
    There is no task too simple for some people to complicate !



    Ford Figo 2016

  26. #16
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by duncang View Post
    Call recorder is a must on your phone. Helped me a few times.
    Alas this was a verbal between SWAMBO and the service provider.
    Now both sides have back-tracked.

    Seems like one needs a written quote these days.
    Jakes Louw
    2012 Jeep Sahara Unlimited 3.6 V6
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  27. #17
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    Default Re: Does your medical aid cover what you think it covers?

    You break penis, we only fix vagina.

  28. #18
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by Peter1949 View Post
    What gets me is when the costs / procedures are pre-approved / authorized whatever - then afterwards (about a year later) you will get a bill threatening legal action to collect Rejected Medical Aid claims.
    By then you cannot any longer claim on GAP cover - past the deadline.
    Then if you look up on your member monthly claims statements you will find a code indicated that a negotiated settlement was reached on the charges levied and that medaid paid at those rates.
    It sometimes even states "Patient not liable".
    Other issues are path and blood test labs not being paid since they did not received the required or authorized or requested forms from someone (??) usually the lab itself or the hospital ?
    These things come to your attention after the deadlines for claiming have passed, so no chance to claim on GAP - which in any case only covers shortfalls on charges (differences) between medaid rates and charged rates. If the amount was rejected by medaid anyway - then no cover.

    Now I am not speaking of Discovery or any other particular medaid - this seems to be the norm.
    We have been on different plans over the years - no different.

    To be fair \i must say that over 95% of substantial costs HAVE been covered and paid, but usually after a lot of hastle, correspondence and follow up.
    Not something I enjoy doing in my so called golden years.

    OK, rant over - but someone else started it.

    This comes down to people no longer caring, no longer giving a flying fluck about their work, no pride in what they do etc.

    We assume the doctor's office will spot a problem and contact us or the medical aid, we assume the medical aid will spot a problem and contact us, but no, that falls outside their job description so they just chuck the file to one side.

    Just last week a friend told me he is having a huge fight with his medical aid at the moment, after taking his child to the doctor he got told he has no MSA left for the year but he is supposed to still have plenty money left. After some tracing he discovered that it's the doctors office who has been making a brain dead mistake for months already, him and his dad has got the exact same name and surname, so every time when his mom and dad went to the doctor the last couple of months they have been putting it on his medical aid and not his dad's. The doctors office isn't very interested in sorting it now and the medical aid isn't much interested in stories, says he should sort it out with the doctor.

    I changed to a different medical aid from the beginning of September, right at the end of August I was at the doctor for a check up. The doctor then sent me a script, but with my old medical aid details on it.
    I contacted the doctors office to ask them to change it to my new medical aid details since I know there will be issues down the line if the wrong details is on the script. I first had to go in to the doctors office to open a new medical file since they apparently can't take down a new medical aid number and plan name over the phone or via email. Irony is, while standing in their office I anyway emailed them a copy of my ID and medical aid card.
    This is however still a ongoing saga, I still haven't received my new script with the new details, fortunately the medication isn't critical and a month won't make any difference. I bet what they actually want me to do is to pay for another consultation to have it changed, but I won't.
    "The man who does not read has no advantage over the man who cannot read" - Not Mark Twain

  29. #19
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by bigboy529 View Post
    We assume the doctor's office will spot a problem and contact us or the medical aid, we assume the medical aid will spot a problem and contact us, but no, that falls outside their job description so they just chuck the file to one side.
    Yep, seems common across the industry.

    So my saga continues: sent an email to the Dr asking for a full invoice so that I can reconcile. Not half an hour later the clerk phones and gives my wife lip about the outstanding amount that shouldn't have been outstanding but now is..........

    So I ask where my invoice is. And around and around we go.
    Jakes Louw
    2012 Jeep Sahara Unlimited 3.6 V6
    Percivamus

  30. #20
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    Default Re: Does your medical aid cover what you think it covers?

    Quote Originally Posted by jelo View Post
    Alas this was a verbal between SWAMBO and the service provider.
    Now both sides have back-tracked.

    Seems like one needs a written quote these days.
    Best to always get the confirmation via email, also makes it easy to dredge it up at a later date.

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