Members owe the scheme between R22 000 and R37 000.
Discovery Health says it has reprocessed claims on its Discovery Health Medical Scheme (DHMS) after a processing error resulted in claims being incorrectly paid out at a higher rate than the plan’s benefits allow.
The claims were initially processed between January and December 2025.
Error
The error relates to the Above Threshold Benefit (ATB) on the Executive, Classic Comprehensive, Classic Smart Comprehensive, Classic Priority, and Essential Priority plans, which affected how certain prescription and over-the-counter medicines were processed in 2025.
“Because of this error, certain of your claims were counted toward and paid from the Above Threshold Benefit (ATB) at a higher rate than what the benefits allow,” Discovery Health COO Karen Sanderson informed affected clients in a letter seen by The Citizen.
Discovery reprocessed the affected claims, with some requiring a co-payment at the time of claiming, which Discovery incorrectly covered.
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Error fixed
In the communication, members owe the scheme between R22 000 and R37 000.
In a statement to The Citizen, Discovery Health said it identified and resolved a system error that affected how certain medication claims for DHMS members in 2025 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.”
Pay back the money
Discovery Health said that “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.”
Rules
According to Rule 15.5, “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.”
Discovery said affected customers will receive a statement detailing how much they owe.
“We’ll contact you to arrange a payment plan that works for your circumstances, as you will need to repay this amount back to the scheme.”
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2026 benefits
Discovery said members’ 2026 benefits won’t be affected.
“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.
Discovery Health said 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.
“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,” it said.
Frustrations
Discovery members took to social media to vent their frustrations about repaying the money, with many already bearing the burden of paying for school uniforms and stationery for their children ahead of the 2026 school academic year.
“Not only have I received this as well, but if you go to a doctor and pay the doctor directly, then claim back, they will deduct the amount they are supposed to pay you against that debt. No communication, no agreements entered, nothing. They just take it,” Gary Bernstein claimed on the Facebook page. “How I was messed around by Discovery Health Medical Aid.”
Mina Sean du Plessis on the same Facebook page wrote: “Oohhh Discovery just knows how to get your year started in a great way…. The time has come for me to take Discovery to CMS. How is the process working with CMS against Discovery? Is CMS really helpful? How many of you got an email stating they made an error and you owe them money now?”
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