After the Bell: Discovery Health gives you another reason to hate your medical scheme

At first, I was not entirely sure about Whelan's claim of a three year window to claw back funds. I mean, if that is the case, three years is a long time. A medical aid could well overpay someone and find two and a half years later that that person is no longer a member of the medical scheme.

And then what?

But, as can happen from time to time, it’s taken me a long time to get closer to the truth.

And, after spending a lot more time than I ever thought possible searching the through the minutiae of the law around medical aid schemes, on balance, I think Whelan must be right.

I can find no reference to any time limit for a claw back.

Of course this is probably not the final word on the matter. Hyman for one is pretty clear on his version. And at some point we may get a ruling from the either the Council for Medical Schemes or a court.

But for now, I think, I must accept Whelan’s view.

Of course, after all of this, you still might have a pretty low view of medical aid schemes and the people who administer them.

I’m not sure how your first day back at the office was, or whether it was today or last week. But I am almost certain that the vibe in your office right now is better than what’s going on at the top of that shiny Discovery edifice in Sandton.

It is extraordinary that an organisation as media savvy as Discovery Health has so completely messed up a simple problem.

In case you were away, or simply felt Sandton should be ignored during the break, the story is pretty simple.

Right before Christmas Discovery Health emailed about 16,000 of its members, saying it had made a mistake with the way it had reimbursed their pharmacy expenses.

Instead of the scheme implementing the normal limit for those costs, those members had been reimbursed. Now, Discovery Health wanted the money back. In fact, it was already taking steps.

The affected members would not be reimbursed for their medical costs until the difference had been made up.

You can imagine the feeling.

You skip into your pharmacy at the start of January, only to find that you are liable for all of your costs for probably the whole year. And you are expected to keep paying Discovery Health anyway!

This would have a huge impact on some patients, and even on some businesses. At least one optometrist I know is busiest in January because people suddenly have funds in their medical aid accounts.

You can imagine the outcry. It became the middle-class story of the holidays.

And it was made worse by what can only be described as a train-crash interview by Discovery Health’s CEO, Ron Whelan, with Cape Talk’s John Maytham last week.

I have known Maytham ever since I was his intern in 1996, and have the pleasure of working with him now. I could have told Whelan not to argue with him.

It was inevitable that Discovery Health would cave eventually. The administrator (not the scheme) said they would make up the shortfall from their own funds.

In case you are struck with a sudden pang of sympathy for Discovery Health, let me remind you that the administrator made a profit of R4.3-billion for the year to the end of June 2025.

Perhaps the strongest argument that could be made for why Discovery Health had a case to claw back the money was that it could affect other members of the fund.

If you were a member of the Discovery Medical Aid Scheme and you realised other people had benefited while you had not, you might think that you would be out of pocket.

But that’s not the case.

The error here was entirely on the part of Discovery Health, which is the administrator of the Discovery Medical Aid Scheme. Discovery Health is for-profit (and generally quite a lot of it) while the Discovery Health Medical Aid Scheme is not-for-profit.

However, MediCheck CEO Mark Hyman told me on The Money Show last week, that “a medical scheme has 30 days to dispute a claim. The member has 60 days to reply and then there can be a clawback.”

What Daily Maverick has been able to confirm is that from the time a member complains to the Council for Medical Schemes, the scheme has 30 days to address the dispute.

According to Hyman, Discovery Health never had a case here.

Even before this I’m sure that if you or a family member are using a medical scheme you’ve had that sneaking suspicion that somewhere, somehow, you’re getting screwed. That you’re not really getting value for money.

Of course, I do know people who have found themselves facing a sudden and awful medical emergency, something that makes me think I may not see them again. Then, two months later, they’re back, hale and hearty again.

The cost of that is astronomical. People tell me about medical bills that come to well over R1-million, yet they are financially whole because of their medical scheme membership.

But I know so many more people who have never faced that and have a very different view.

In the US so many people hate their “health maintenance organisation” that “HMO” has become a kind of swear word.

They appear to be good for just one thing: providing the villain in so many legal dramas.

I would love to know what happened at Discovery Health over the weekend, who phoned who and who was called in to fix it all.

But it’s a start to the year they’ll probably remember for some time. DM