Frequently asked questions
About Discovery Health Medical Scheme
Discovery Health administers the Discovery Health Medical Scheme. A medical scheme is a not-for-profit entity governed by the Medical Schemes Act. Members of a medical scheme pay contributions every month and in return, receive medical cover according to the rules of the scheme and clinical best practice. Member contributions are paid directly into a pool of funds. Any money not paid out in claims, administration fees and other non-healthcare expenditure remains in this pool. Overseen by a Board of Trustees, this pool of funds belongs solely to the members. An administrator manages the operations of a medical scheme. It earns a fixed administration fee for each family, every month from a medical scheme, in order to carry out a full range of administration services.
Joining Discovery Health Medical Scheme
Joining is easy. Get a medical aid quote online, call us on 0860 000 628 or contact your financial adviser.
You need to let Discovery Health Medical Scheme know 30 days in advance (a calendar month's notice) of your intention to withdraw yourself or your dependants from the scheme. Contact us on 0860 99 88 77 or email firstname.lastname@example.org.
You cannot withdraw money from your Medical Savings Account but we will pay any positive balances from your MSA if:
- You have resigned from the Scheme
- You have downgraded your health plan to a plan that does not offer a Medical Savings Account
Money are paid on the first claims run in the fifth month after the effective withdrawal date. This is to allow for the payment of late claims.
Schemes can apply waiting periods because you have never belonged to a medical scheme or you have had a break in membership of more than 90 days before joining Discovery Health Medical Scheme. You will not have cover or access to the Prescribed Minimum Benefits during your waiting periods. This includes cover for emergency admissions.
The Medical Schemes Act allows medical schemes to apply a late joiner penalty if an applicant, or the dependant of an applicant, who at the date of application:
- Is 35 years or older; and
- Was not a member or a dependant of a registered South African medical scheme (foreign schemes are not recognised) on or before 1 April 2001; or
Has allowed more than a 3 month consecutive break in membership since 1 April 2001.
Simply request a new card by contacting us on 0860 99 88 77 or email us at email@example.com. While you wait for your new card you can use a membership certificate or digital card as proof of membership. Your medical aid membership certificate is available under Policy documents on the Health navigation of the Discovery app. Also, when you log in, you can view it online. To view your digital card, log in on the Discovery app using your website login details and access it under Digital cards on the main menu.
Discovery Health Medical Scheme complaints process
Discovery Health Medical Scheme is committed to providing you with the highest standard of service and your feedback is important to us. The following channels are available for your complaints and we encourage you to follow the process.
- Step 1 - If you have already contacted us and feel that your query has still not been resolved, please complete our online complaints form. We would also love to hear from you if we have exceeded your expectations.
- Step 2 - If you are still not satisfied with the resolution of your complaint after following the process in step 1 you are able to escalate your complaint to the Principal Officer of the Discovery Health Medical Scheme by completing the online form.
- Step 3 - If you have received a final decision from Discovery Health Medical Scheme and want to challenge it, you may lodge a formal dispute.
- Step 4 - Discovery Health Medical Scheme is regulated by the Council for Medical Schemes (CMS). You may contact the CMS at any stage of the complaints process but are encouraged to follow the steps above to resolve your complaint before contacting the CMS directly. Members who wish to approach the Council for Medical Schemes for assistance, may do so in writing to: Council for Medical Schemes Complaints Unit, Block A, Eco Glades 2 Office Park, 420 Witch - Hazel Avenue, Eco Park, Centurion, 0157 or email firstname.lastname@example.org. Customer care centre: 0861 123 267 / website www.medicalschemes.com
PMB and other important concepts to help you understand your health plan
In terms of the Medical Schemes Act of 1998 (Act number 131 of 1998) and its regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- any life-threatening emergency medical condition
- a defined set of 270 diagnoses and
- 27 chronic conditions.
These conditions and their treatments are known as the Prescribed Minimum Benefits (PMB).
All medical schemes in South Africa have to include the Prescribed Minimum Benefits in the health plans they offer to their members. There are, however, certain requirements that a member must meet before he or she can benefit from the Prescribed Minimum Benefits.
The three requirements are:
The Medical Savings Account (MSA) is an amount that gets set aside for you at the beginning of the year or when you join Discovery Health Medical Scheme. You pay back this amount monthly as part of your medical scheme contribution. Members on the Executive, Comprehensive, Priority and Saver plans get a Medical Savings Account. We pay for day-to-day medical expenses like GP visits, radiology and pathology from the Medical Savings Account, as long as you have money available. Any money remaining in the Medical Savings Account at the end of the year will carry over to the next year.
If you leave the Scheme or downgrade your health plan before the year is up, you may owe the Scheme the portion of the Medical Savings Account you have used but have not yet paid back.
The Self-payment Gap (SPG) is a temporary gap in cover when you run out of funds in your Medical Savings Account (MSA) but have not yet reached your Annual Threshold. You will have to pay for day-to-day claims from your own pocket during this period. You must still submit claims to us so that we know when to start paying from your Above Threshold Benefit. Watch this short video for more information or read more here.
The Above Threshold Benefit (ATB) is a 'safety net' included on Discovery Health Medical Scheme’s Executive, Comprehensive and Priority Plans. The day-to-day claims that you submit to Discovery Health Medical Scheme are added up at the Discovery Health Rate depending on the limits for any specific treatment and conditions. Once the claims add up to a certain amount, known as the Annual Threshold, your claims start paying from the Above Threshold Benefit. You may run out of money in the Medical Savings Account before we start paying from the Above Threshold Benefit. This is called a Self-payment Gap.
A benefit is a pool of funds in a medical scheme reserved for specific healthcare services. For example, the Hospital Benefit pays for healthcare services when you are admitted to hospital as part of an approved admission.
A limit is the maximum amount or a cap on what we will pay for a particular type of healthcare service. This applies when the service is paid from a specific benefit. For example, your optometry claims either pay from the Medical Savings Account or Above Threshold Benefit but we will only pay these claims up to the optometry limit for your health plan. Watch this short video for more information.
You can send in your claims in one of these ways:
- Discovery app for your iPhone or Android smartphone lets you take a photo of your claim
- Scan and upload your claim here
- Email to email@example.com
- Post to Discovery – Claims, PO Box 784262, Sandton, 2146
- Fax to 0860 329 252
- Claims drop-off boxes situated at medical practices, pharmacies and Planet Fitness and Virgin Active gyms countrywide
To track the progress of your claims, you can use the Claims Search tool when you log in, or you can call 0860 99 88 77 and follow the phone voice prompts, or just SMS 'Claim' to 31347.
You must send us your claim within four months from the date you saw your healthcare professional.
If your healthcare professional has sent us the claim, you do not need to send us another copy. Please keep this copy for your records.
Your condition must be covered on our list of conditions. Please visit your doctor who will help you complete a Chronic Illness Benefit application form. The completed application form can be sent to us through:
- Fax to 011 539 7000
- Email to CIB_APP_FORMS@discovery.co.za
- Post to Discovery Health, CIB Department, PO Box 652919, Benmore, 2010.
Discovery Health may ask you for motivation with your application form. Where applicable please check if you have submitted all the relevant documents needed to process your application.
Discovery Health Medical Scheme covers each procedure according to the benefits available on your health plan. Discovery Health Medical Scheme members can see if their procedure or treatment is covered with our ‘Do We Cover” tool. If you need to go to hospital, you must call us to confirm your admission to hospital. We will explain how your procedure will be covered.
Use the Do We Cover tool for your specific procedure
In an emergency, go straight to hospital. If you need medically equipped transport, call 0860 999 911. Highly qualified emergency personnel manage this line. They will send air or road emergency evacuation transport to you, depending on which is most appropriate. Remember that you, a loved one or the hospital must let us know about your admission as soon as possible.
If you have a medical emergency while overseas, call International SOS on +27 11 541 1222 with your membership number as printed on your membership card.
Find out more about what to do in an emergency.
We enter into agreements with healthcare professionals to ensure certainty of cover for our members and higher levels of reimbursement for healthcare professionals who we pay in full. Our agreements cover 90% of GP and specialists visits respectively.
You can a find a healthcare professional we have an agreement with when you log in.
Travelling outside of South Africa
The Africa Evacuation Benefit covers you for emergency medical evacuations from certain sub-Saharan African countries back to South Africa. You can find the list of African here.
The International Travel Benefit offers medical emergency cover, for 90 days from date of departure, outside the borders of the Republic of South Africa to members on all plans (excluding KeyCare plans).
Each person is covered up to a limit of R10 million on the Executive Plan and R5 million on the Classic, Essential or Coastal Plans.
If you are going to travel for more than 90 days, you must apply for extra travel insurance from your travel agent before your departure from South Africa.
Having a baby
Once you are 12 weeks pregnant you can contact us on 0860 99 88 77 to authorise your admission. Cover is subject to your health plan’s benefits and rules. Once you let us know we will give you a hospital authorisation number. You will also get a letter and your maternity brochure explaining your benefits.
The baby will be covered automatically for the calendar month of his or her birth. To continue cover, contributions for the baby must be paid from the first month following the baby's birth. You need to complete a newborn application form and submit it to us to ensure that your baby is covered. The baby may be subject to underwriting, if he or she is not registered within the 30-day period.
Note: Please register your newborn with the department of Home Affairs within 21 days from birth and send us a copy of the birth certificate as soon as possible.
Once you log in you get application forms and benefit brochures.
Discovery MedXpress is a convenient medicine delivery service, particularly for monthly medicine repeats. Members can order their medicine over the phone, on the Discovery app and online and have it delivered to an address of their choice or collect it from a pharmacy (available at Dis-Chem from 1 February 2015 and at Clicks later in the year).
Discovery MedXpress is the designated service provider for chronic medicine on all Delta and Core plans.