Sommige lede moet geld aan Discovery Health terugbetaal

GAUTENG. – Discovery Health het in Desember 2025 ’n stelselfout geïdentifiseer en reggestel wat sekere medisyne-eise van lede van die Discovery Health Medical Scheme (DHMS) beïnvloed het. Volgens Discovery Health het die fout veroorsaak dat sommige lede van die Executive-, Comprehensive- en Priority-planne hul Above Threshold Benefit (ATB) vroeër as verwag bereik het, met sekere eise wat verkeerdelik uit die ATB befonds is.

Discovery Health sê aan Nuusflits die fout het slegs ’n klein groep lede geraak. “Alle geraakte eise is weer verwerk sodat dit uit die korrekte voordele befonds word, hetsy mediese spaarrekeninge of die selfbetaling.” Lede se mediese voordele en dekking vir 2026 word nie beïnvloed nie en gesondheidsverskaffers is nie negatief geraak nie.

Die skema het ook begin met die verhaal van te veel befondsde bedrae volgens die Medical Schemes Act en interne reëls om billikheid te verseker. Discovery Health sê hulle werk nou saam met elke geraakte lede om die aanpassings op ’n ondersteunende manier te bestuur en het ekstra kontroles ingestel om toekomstige foute te voorkom. Alle geraakte lede sal verder ingelig word met gedetailleerde state en rekonsiliasies.

Op die Eks Van Die Ooste Facebook-blad het verskeie persone gesê daar word van hulle verwag om astronomiese bedrae terug te betaal. Sommige het selfs gewonder of dit nie ‘n bedrogspul (scam) is nie. Die groot vraag wat lede vra, is hoe lede verantwoordelik gehou kan word vir ‘n fout wat nie hulle skuld is nie.

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Please see Discovery Health and Discovery Health Medical Scheme’s full statement below: 

In December 2025, Discovery Health identified and resolved a system error that affected how certain medicine claims for members of the Discovery Health Medical Scheme (DHMS) were funded. While only a small proportion of Scheme members were impacted, we sincerely apologise for the inconvenience caused. All affected claims have been corrected, members are receiving proactive support, and stronger controls have been implemented to prevent a recurrence. 

The error resulted in some members on Executive, Comprehensive and Priority Plans reaching their Above Threshold Benefit (ATB) earlier than expected, with certain claims incorrectly funded from ATB during 2025. Importantly, members’ 2026 medical benefits and medical aid cover and access are entirely unaffected by this error, and no healthcare providers have been negatively impacted. 

To ensure benefits align with Scheme Rules and regulatory requirements, all impacted claims have been reprocessed so that they are funded from the correct benefits, either Medical Savings Accounts or the Self-Payment Gap. The claims processing systems are functioning entirely correctly, and additional safeguards and validation checks have been introduced to prevent similar issues in future. 

The Scheme has also commenced a recovery process for over-funded amounts, ensuring fairness, consistency, and regulatory compliance across the Scheme. We recognise that unexpected adjustments can affect personal budgets and planning, and we are working closely with each affected member to manage this in the most appropriate and supportive way. 

We deeply regret this error and sincerely apologise for the frustration this has caused. Discovery Health and DHMS take this incident extremely seriously and remain committed to earning and maintaining members’ trust through strong operational discipline, robust controls and oversight, and transparent communication with ongoing support for all affected members. 

In addition, to provide additional information, please see extra detail below: 

• The system error has affected a small proportion of Scheme members and only certain members on Executive, Comprehensive and Priority plans where the Above Threshold Benefit applies.  
• Although deeply regrettable and unfortunate, Discovery Health makes every effort and investment in preventing such errors. As a result, errors such as these occur very rarely. 
• In the interests of ensuring integrity of the Scheme rules and treating all members of the Scheme fairly, the Scheme is obligated to recover funds where members have inadvertently received disproportionate benefits that they unfortunately weren’t entitled to. 
• All recoveries are being managed strictly in accordance with the Medical Schemes Act, Council for Medical Scheme rules and regulations, and DHMS’ Rules 15.5 and 16.4.  
• Rule 15.5 states that if the Scheme, for any reason, pays an amount more than which it is liable to pay for a claim, then the Scheme can recover this through payments due to the member. Additionally, Rule 16.4 states that when the Scheme has paid an account, or portion of an account, or any benefit that a member is not entitled to, the amount of such overpayment is recoverable by the Scheme.  
• We deeply regret the error and the inconvenience that this has caused. We are working closely with all impacted members to provide the appropriate support wherever required.  
• Further details will be shared with impacted members during the course of January, including detailed statements and reconciliations. 
• Although very infrequent, it is not unprecedented for medical schemes to recover overpayments made in error