Discovery medical aid keeps woman on the ropes over payment

Zisanda Nkonkobe’s low haemoglobin count brought her to the brink of death when she was diagnosed earlier in September with auto-immune haemoglobin anaemia, a rare condition involving the breakdown of oxygen-carrying red blood cells through the body.

Her haemoglobin count was 4.5 grams per decilitre, a third of the normal range.

The 35-year-old mother urgently needed a blood transfusion but no blood with the appropriate antibodies was available to her.

So, haematologist Dr Michael Webb prescribed Polygambranded immune globulin, a human plasma solution to aid the body’s fight against infection. The treatment was successful and Nkonkobe was discharged from Life Beacon Bay Hospital on September 9.

But Nkonkobe’s Discovery medical aid refused to pay for the R38,000 treatment, stating that it showed “no real benefit” to the patient’s “long-term health”.

When I queried the basis on which payment for the treatment was declined, Discovery said it had already advised the hospital that it would meet the claim.

However, while it stated that it had approved the claim on appeal on September 11, three days later it was communicating verbally and via e-mail with Nkonkobe to the effect that the claim had been dismissed.

The ill, stressed-out woman waited almost two weeks before Discovery informed her that they had agreed with the hospital to pay the bill – but had not bothered to tell her.

The medical aid’s reputation consultant, Khensani Mthombeni, said: “We received the request to review from the hospital, hence feedback was given to the hospital.”

In their initial communication with Nkonkobe, Discovery provided no detailed reasons why their claim administrators had countermanded a doctor’s treatment plan.

They also said nothing about any process that Nkonkobe could follow to appeal their decision.

I asked Discovery what the basis was for the medical aid’s determination that there were no long-term benefits to Nkonkobe for the prescribed treatment.

Other questions were:

  • What medical trial or other studies did Discovery rely on in coming to this conclusion?
  • Was Discovery willing to consider an alternative treatment for auto-immune haemoglobin anaemia that has shown greater efficacy in long-term patient health, weighed against its understanding of the risks of Nkonkobe’s condition?

None of these three questions was addressed in Discovery’s reply.

Nkonkobe said she “could have died” without the plasma treatment.

She said Discovery never provided any information suggesting the claim had been approved on appeal by the hospital.

“Instead they sent me a copy of my claim,” Nkonkobe said.

RAY HARTLE

Discovery medical aid keeps woman on the ropes over payment

One thought on “Discovery medical aid keeps woman on the ropes over payment

  • 30th September 2019 at 4:34 pm
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    i wish that medical aids were run by people who had the well being of their members at heart. there is a big difference between what is legaly correct and what is humane and considerate.

    Reply

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