Discovery Well being has requested a few of its medical support members to repay cash after an inner processing error led to claims being paid at increased ranges than their plans enable.
The problem impacts members on 5 of Discovery Well being Medical Scheme’s higher-tier plans: Govt, Basic Complete, Basic Good Complete, Basic Precedence and Important Precedence.
On the centre of the issue is the Above Threshold Profit (ATB), which covers sure day-to-day medical prices as soon as a member has spent a set quantity for the 12 months.
Whereas the ATB kicks in after this threshold is reached, it additionally has its personal limits. As soon as these limits are exhausted, additional claims ought to both be paid from a member’s medical financial savings account or by the member themselves.
Nevertheless, Discovery Well being says that between January and December 2025, some claims continued to be paid from the ATB even after these limits have been reached.
Consequently, the scheme lined prices that ought to not have been paid.
In different phrases…
Below regular guidelines, Discovery Well being pays totally different percentages of the Discovery Well being Price (DHR): 0% for over-the-counter medicines, 50% for high-cost non-preferred medicines, and 75% for some non-generic medicines.
Due to the processing error, all of those claims have been incorrectly paid at 100% of the DHR.
Discovery Well being demanding reimbursement
Discovery Well being has since reprocessed the affected claims and contacted impacted members, informing them that they now owe the scheme the worth of these incorrect funds. In some instances, the quantities run into tens of 1000’s of rand.
In accordance with reviews, a few of these reimbursement requests vary from about R22 000 to R37 000.
The administrator has not disclosed precisely what number of members are affected however says it’s a “small proportion” of the scheme.
Members have obtained up to date statements exhibiting the quantities owed, together with notices explaining that the scheme will contact them to rearrange reimbursement plans. Discovery Well being says it’s keen to work with members to agree on cost phrases.
The corporate says it’s legally required to recuperate overpaid advantages to make sure equity throughout the scheme and that recoveries are being dealt with according to medical scheme guidelines and laws.
Discovery Well being has confused that members’ 2026 advantages, cowl and entry to healthcare suppliers usually are not affected. It additionally says extra controls have been put in place to forestall the same error from occurring once more.
