On 21/07/2013 I had an emergency procedure by a surgeon for a serious condition after hours in hospital for a PMB condition. Discovery said they will pay only R1588 of the surgeons account of R4959 (Dr. NM), ie an outstanding balance of R3371.
I have sent proof to discovery that it was a PMB condition (the doctors motivation letter & pathology lab proof). The treatment received matched the treatments in the PMB defined benefit.
As it was a serious emergency after hours (Sunday) I DID NOT HAVE A CHOICE OF PROVIDER, ie I was able to see only the one orthopaedic surgeon who was on call.
The medical schemes act states "A MEDICAL SCHEME MUST PAY IN FULL, WITHOUT CO-PAYMENT OR THE USE OF DEDUCTIBLES, THE DIAGNOSIS, TREATMENT AND CARE COSTS OF A PRESCRIBED MINIMUM BENEFIT CONDITION"
Discovery Health is thus obliged to settle the outstanding amount in full.
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