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PostPosted: Thu Feb 02, 2012 2:31 pm 
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Joined: Mon Mar 26, 2007 10:57 am
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Location: CT
Real Name: Paul P
Short version: I broke my leg. Discovery Health will not pay. Leave while you can before they screw you too. :thumleft:


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PostPosted: Thu Feb 02, 2012 2:35 pm 
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Sorry to hear that. How did you break your leg? I broke my hand bouldering and they would not pay either, but that is because I am on a hospital plan and apparently it only counts if you actually spend the night in hospital and not on whether you actually visit a hospital emergency room. Either way it sucks. Not sure whether they specifically cover climbing or not - I just assumed they did - if not then who covers climbing injuries?


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PostPosted: Thu Feb 02, 2012 2:39 pm 
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Joined: Mon Nov 19, 2007 3:13 pm
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They've got this insane rule that they only pay if you spend the night. Off course it cost them much more that way. From all the broken bones I had they only paid for 2 I think, I spend 4 nights for the one and 1 night for the other. So basically all you need to do is break your leg properly next time :eye:


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PostPosted: Thu Feb 02, 2012 2:42 pm 
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Real Name: Franz Fuls
Sorry to hear, proze. that sucks. :pukel:
When recently changing medical aid, I specifically asked if adventure sport ie climbing is covered and received confirmation before joining. I suggest everyone does this with your current medical aid. These boys are not in business to pay out, but to make money. Be very aware of who you are dealing with.


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PostPosted: Thu Feb 02, 2012 2:45 pm 
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Location: Montagu
Real Name: Justin Lawson
Sorry to hear about your leg Proze!
I'm also with Discovery.

Q's:
- What Discovery plan are you on?
- How did the accident happen and did you mention rock climbing to them? (climbing is considered a high risk activity and not covered by most insurance companies).
- What reason did they give for not covering you?

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PostPosted: Thu Feb 02, 2012 3:18 pm 
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Location: CT
Real Name: Paul P
I broke my leg walking on Lion's Head. Nothing crazy (well, the descent was afterwards, ask vander!). But they pull this "you weren't admitted" nonsense. But a broken leg is a PMB. By law they have to pay. But they are refusing to pay for the xrays that were taken to determine the extent of the injury, the cast that was put on or the specialist who had to see if I needed surgery. Have you ever seen someone with a broken leg that didn't have a cast? Or who didn't have xrays? Anyway, I've run myself ragged getting all the info they wanted and spent hours and hours on the phone, all for nothing. So I'm moving everything from them, lock, stock and barrel.

Sorry, plan: I'm on a Coastal Saver.

2nd edit: Just a note: it's f*cking CRAZY that there even has to be a PMB to force them to pay for a broken bone!! Think about it! It's bloody mad but we all just accept it.


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PostPosted: Thu Feb 02, 2012 3:25 pm 
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I've been thought this debate plenty of times.

Be VERY careful:
Recently, after I specifically discussed this with a broker, I was told that all is fine, and everything is covered.
When I tested her against my usual broker it was clear that she did not know sh!t.

Most agencies will not cover rock climbing, but will cover activities like deep-see-diving.
(...."with or without a rope".....if I may quote them)

There is also sub-clause in some life insurance policies:
It you die climbing they will pay out, but if you are disabled due to an injury the will not.
(...or was it the other way round....?)

I'll put my broker onto this topic.
Working specifically with my rock climbing for about 15 years now, he has tested the system thoroughly.
So, for climbing related insurances I would recommend him.


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PostPosted: Thu Feb 02, 2012 5:09 pm 
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Location: Waterval Boven
Real Name: Jan Bradley
Discovery ropes people in with gym discounts, movie vouchers and what not but they don't do what they are there for, pay for medical expenses. Try Medihelp been with them since 1992 and never had a problem. My hospital plan paid for a MR scan last year, wasn't even admitted and they cover climbing and other "extreme" sports, specifically asked about this when I took out my own plan a number of years ago.


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PostPosted: Thu Feb 02, 2012 5:14 pm 
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Joined: Thu May 05, 2005 5:39 pm
Posts: 304
Location: JHB
You are referring to Prescribed Minimum Benefits (PMB's)
PMB's are minimum benefits which by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:

any emergency medical condition
a range of conditions as specified in Annexure A of the Regulations to the Medical Schemes Act (No 131 of 1998), subject to limitations specified in Annexure A. Included in this list of conditions is the list of chronic conditions


Think you are looking for this document: http://www.doh.gov.za/docs/regulations/1999/reg1262.pdf

Check out these as well
10 Things members need to know about Prescribed Minimum Beneļ¬ts (PMBs)
1. http://www.bhfglobal.com/files/bhf/CMS% ... embers.pdf

10 Things your members need to know about PMBs
2. http://www.bhfglobal.com/files/bhf/PMBs ... chemes.pdf

Hope this helps.

If you have a rock solid case fight them for your cash.

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PostPosted: Thu Feb 02, 2012 5:20 pm 
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Location: JHB
Also, if you do have an injury that falls under the PMB list and you go directly to one of your schemes DSPs (designated service providers) they have to pay the full amount AFAIK.
If it's an emergency and you turn up at another service provider they have to cover casualty costs & the cost to stabilize you (AFAIK) and should you choose to stay at the non-DSP they should cover their typical medical aid rates or if you are then moved to a DSP they should cover the total cost.
This is all my understanding of PMB, DSP etc, so I'm happy to be corrected where necessary.

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PostPosted: Thu Feb 02, 2012 5:42 pm 
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Real Name: Paul P
Thanks Mark, that is all as I understand it. I've been told in no uncertain terms, by the specialist, that my injury is coded as a PMB and they should pay for everything. They just refuse and bury you in call-centre hopelessness and suffering.


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PostPosted: Thu Feb 02, 2012 5:47 pm 
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Joined: Fri Dec 15, 2006 12:32 pm
Posts: 1141
Location: Cape Town
Real Name: Willem Boshoff
ha! pay sucker :mrgreen:

oaky seriously, in addition to the stuff said above:

differentiate between life insurance (death & disability benefits) and medical aid.

most life insurance excludes rock climbing - the guys simply do not have the skill & data to price it. some specialist guys like Altrisk do however (they reinsure to big multi-national players that can price this). chat to you broker & make sure that rock climbing related death / injury is not excluded! if it is excluded they will not pay.

medical aid: the cheapest plan will cover the least and will exclude, sometimes by means of completely unintelligible medical terms, a lot of problems. that's why it's cheap. closed / employer based schemes often pay without fuss but the premiums are also generally higher. again, make sure that you are covered for pratical eventualities i.e. say "if i break a leg and has to get treatment, will they pay in all circumstances". pain in the butt, but make the effort.

imho discovery's clause of "overnight hospitalisation" is a schmokkel - for the extact same injury they may or may not pay depending on the doctor's advice (or even the time of day you got injured). i think it's unethical but that's the way it is. so, just take your business somewhere else.

there is an ombudsman for life, short term and medical insurance. if a claim is repudiated on grounds that are not 100% clear and according to contract, get the ombudsman on their case.

bottom line: get a good broker that know what they do to make sure you're properly covered for life, disability & medical expenses.


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PostPosted: Thu Feb 02, 2012 5:51 pm 
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Joined: Fri Dec 15, 2006 12:32 pm
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Location: Cape Town
Real Name: Willem Boshoff
oops, okay, medical schemes does not have an ombudsman but here's your recourse:

"Got a problem with your medical scheme, hospital, doctor, dentist, nurse, pharmacist or optometrist? Here's where to go for advice and complaints

Council of Medical Schemes is the one to call. Their web site has a "complaints zone" where a complaint can be both filed and tracked online. Before submitting a complaint, you must first follow your medical scheme's internal complaints procedure though."

http://www.medicalschemes.com/Content.aspx?110

and hit them with hello peter.

good luck tjom.


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PostPosted: Thu Feb 02, 2012 6:02 pm 
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Oh yeah and the other scam which is not necessarily medical aid related is when you are at the hospital they just shuffle you from one person to another and don't really explain what is going on. I got a separate bill for R800 from the occupational therapist who spent 2 minutes with me and told me I should open my hand every now and then to aid the healing of the broken bone. Swines.


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PostPosted: Thu Feb 02, 2012 10:24 pm 
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Joined: Mon Feb 21, 2011 8:45 pm
Posts: 222
Real Name: Franz Fuls
I think I am going to open my own medical scheme, and get intoxicated with serious mind altering substances - jim morrisson style - before starting to write the benefit and exclusions clauses. Sounds like a great way to make money!


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PostPosted: Fri Feb 03, 2012 10:29 am 
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Joined: Fri Nov 05, 2010 4:04 pm
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Real Name: Wesley Williams
I saw a little girl in an emergency room with her Dad. She had some kind of insect bite. The Dad had to pay R600 for visit because he was a Discovery member. There was a sign in the emergency room saying "Discovery members must pay upfront".

I was going to the physio for a bad shoulder from bouldering too much. My medical aid paid for everything. I think Discovery is screwing you guys.


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PostPosted: Fri Feb 03, 2012 1:35 pm 
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Joined: Wed Mar 17, 2010 8:11 pm
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Real Name: Kevin Dingle
wesleywt wrote:
I was going to the physio for a bad shoulder from bouldering too much. My medical aid paid for everything.


So which medical aid?


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PostPosted: Fri Feb 03, 2012 3:14 pm 
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Posts: 712
Interesting all the complaints here. I've never had anything but good service from Discovery Health. Paid for hand specialists, physios, shoulder specialist, doctor, dentist, optometrists, glasses, contacts, sunnies with no questions ever. Sorry about your leg man, get well soon.


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PostPosted: Fri Feb 03, 2012 3:40 pm 
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Joined: Wed Nov 23, 2011 6:47 pm
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Real Name: paulgoddard
Howdy Proze

Sorry to hear about the leg dude.
I am also on Discovery Coastal Saver.
Came off my Mountain bike on the 17th(Sunday) of September last year, dislocated my clavicle from my breast plate.
They paid for everything, X-rays, Orthopaedic surgeons visits, shoulder sling goodies etc. EVERYTHING !

what i do remember a while ago is that a Discovery consultant asked if i wanted to be covered for extreme sports (mtb, rock climbing etc) and i opted in. i think it costs me an additional R16 a month.
well worth it.
Check with them to see if you can get this ''upgrade'' added to your current policy.
I wish you a speedy recovery dude


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