Discovery Health has taken responsibility for a claims processing error that overpaid benefits to 16,507 members, agreeing to absorb the R125-million cost instead of seeking recoveries from those affected.
A system update in early 2025 led to an error in how certain medicine claims accumulated toward the Annual Threshold for Discovery Health Medical Scheme members. This caused above-threshold benefits (ATBs) to be paid out faster than intended, resulting in overpayments for medicines and services that members should have covered themselves.
The issue affected 16,507 members on Executive, Comprehensive, and Priority plans, the scheme's most expensive options. Discovery Health detected the problem through routine monitoring by its drug risk team and a query from a broker. The total overpayment amounted to about R125-million, which the administrator described as equivalent to 0.1% of the annual claims for these members—R3.6-billion in benefits paid out last year.
Initially, members faced demands to repay sums up to R80,000, causing significant stress. MediCheck, an advocacy firm representing over 1,500 affected members, estimated the disputed recoveries at R130-million to R170-million. Its chief executive, Mark Hyman, praised Discovery's decision: “The decision follows a week of intensive engagement by MediCheck on behalf of affected members who faced recovery demands – in some cases exceeding R80,000 – for an administration error they did not cause.”
One affected member, Lynette, expressed relief: “I am very relieved that Discovery have decided to take responsibility for its error and found the moral courage to do the right thing.” She highlighted the unnecessary pressure from earlier repayment demands.
The Council for Medical Schemes plans to investigate the processes behind the error. This case underscores the value of questioning medical bills and engaging with schemes, as illustrated by a separate anecdote where a consultation fee dropped 66% from R872 to R300 after negotiating a cash payment.
