Discovery defends against lack of transparency allegations

Law firm Ronald Bobroff & Partners Inc., have accused Discovery medical scheme of not being transparent with rules it has surrounding road accident fund and other injury related claims. On its website under the heading ‘A shocking discovery for Discovery medical aid members’ the firm claims that Discovery will not cover medical care costs due to the act of another. The firm explains that cover is excluded unless you agree to recover funds from the road accident fund or go to court to recover costs associated with your cost of care.
 
It added that, “for example: road accidents, workplace injuries, dog bites, assaults etc., are excluded unless you agree with the scheme in writing under threat of immediate termination of medical care and a further threat that you have to refund the cost of care already provided to your or your dependents, to claim from the wrongdoer at your own risk and cost and to thereafter reimburse Discovery in full any medical costs paid by it.”
 
Ronald Bobroff & Partners Inc. goes on to ask whether scheme members had ever received a “detailed summary” of Discovery’s rule when they became members. “Despite the Medical Schemes Act making this compulsory in terms of Section 30 (2) (a) – RBP and many members of the South African Association of Personal Injury Lawyers, are yet to find a single member client of Discovery Medical Aid, who ever received this or ever had the benefit of Discovery complying with numerous compulsory provisions of the Medical Schemes Act,” claims the firm.
 
The firm alleges that “Tucked away in Discovery’s never disclosed rules, is Rule 15.6.1 and Annexure “C” which contains exclusions entitling Discovery to refuse you or your dependents any medical care which is due, “to the act of another” unless you agree at your own risk and cost to claim on Discovery’s behalf against the alleged wrongdoer for repayment of all medical costs paid by Discovery for your treatment. In practice this means you have to bear the cost of your own Attorney, Advocates and medical experts, as also to face the risk of having to pay the defendants/Road Accident Fund’s (RAF) legal costs – which in an ordinary High Court trial usually exceeds hundreds of thousands of Rands – should your claim prove unsuccessful.”
 
Discovery denies allegations
 
Discovery have however this week hit back at the accusations claiming that Mr Ronald Bobroff is doing this in order to “deflect attention from the numerous charges and court orders against him”. Discovery outlined that Bobroff has made a number of unfounded claims including that:
 
1 The Scheme does not adequately inform members of the Scheme rules and, as a result, has no right to be refunded RAF claims in respect of medical costs incurred by the Scheme on behalf of the member.
 
Discovery points out that the Council for Medical Schemes (CMS) has ruled unequivocally on this issue in favour of the Scheme, concluding: “the scheme is entitled to claim reimbursement of medical expenses paid in respect of RAF matters in terms of its rules and in terms of common law principles. The Council also confirmed that Discovery adequately informs its members of these rules and obligations in terms of Medical Schemes Act.
 
2 Discovery Health members and their families are approached while in hospital and forced to sign undertakings to refund the Scheme in respect of RAF reimbursements.
 
“No Discovery Health employee has ever approached a member in hospital in this regard. All Discovery Health members are guaranteed coverage in respect of their medical costs incurred as a result of a motor vehicle accident (as with all our benefits) in line with their plan choice in terms of the Prescribed Minimum Benefits which all medical schemes cover. The Scheme has never failed to pay claims for medical expenses after a motor vehicle accident,” Discovery added in its statement.
 
What happens if you do claim from the RAF or recover funds through a court case?
 
Discovery does point out, however, that if a member or dependent receives compensation from the RAF for medical expenses the member must then refund those amounts previously paid by the Scheme for the member’s medical expenses. It explains: “This is to avoid the member being unjustly enriched at the expense of the Scheme by receiving double compensation for the same health event.”
 
If you don’t claim from the RAF or go to court to recover funds, Discovery says that: “the Scheme will remain liable for the costs of treatment subject to the chosen plan type of the member and will never require that the member repay these funds to the Scheme.”
 
You can’t enrich yourself unjustly
 
Discovery referred Justmoney to a press release issued by the CMS issued on 12 March 2012. In it the CMS explains that if you are in a road accident and a medical scheme member your scheme has to pay for your treatment. But it adds: “But if the RAF pays you out, you must refund a portion of the money to your medical scheme. Moreover, your medical scheme can actually ask that you claim from the RAF and pay the scheme back.”
 
The CMS further outlines that Schemes can ask you to sign an undertaking that you will try to claim costs from the third-party insurer, however it adds: “IF you refuse to sign such an undertaking, your scheme must still cover your treatment costs and cannot refuse to fund the costs of the medical treatment you require, subject to provisions in the Medical Schemes Act 131 and the rules of the Scheme.”