In the letter sent to affected members, Discovery Health indicates that an error affected the processing of claims for prescription and over-the-counter (OTC) medicines between January and December 2025.
Moneyweb reports affected plans include Executive, Classic Comprehensive, Classic Smart Comprehensive, Classic Priority, and Essential Priority plans.
Given the error, certain claims were counted toward and paid from the Above Threshold Benefit (ATB) at a higher rate than the benefit allows.
The usual percentages of the Discovery Health Rate (DHR) are: 0% for OTC medicines, 50% for high-cost-non-preferred medicines, and 75% for certain non-generic medicines.
Due to the error, Discovery Health processed and accumulated all of these at 100% of the DHR.
The scheme is now requesting reimbursement.
“When we reprocessed these claims, some would have incurred a co-payment at the time of claiming, but did not because of the error,” said the scheme in a letter to those affected.
“This means you now owe the scheme the value of those co-payments, as well as any claims that were paid by the scheme but should have been paid by you during your self-payment gap.”
"You therefore received more cover from the scheme than what you qualified for.
"We need to correct this error to ensure that the benefits you received between January and December 2025 are in line with the scheme,” added the letter.
Discovery Health says that it deeply regrets this error and has sincerely apologised for the frustration this has caused.
Adding that it is providing support to the affected members and is implementing stronger controls to prevent a recurrence.
"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 in a statement.
Affected members took to social media to express their dismay after Discovery Health sent out the letter.
The medical claims assistance company Medicheck has created a dedicated email address for those who’d like to review the correspondence from DHMS.
On its Facebook Group page, it has also advised that the affected DHMS members refrain from signing any acknowledgement of debt with Discovery.
It also urged them not to enter into any payment arrangements until the matter is fully investigated via the Fraud, Waste and Abuse Advisory body of the Council of Medical Schemes (CMS).
Discovery Health has indicated that all recoveries are being managed strictly in accordance with the Medical Schemes Act, CMS rules and regulations, as well as the medical scheme's rules 15.5 and 16.4.
The medical scheme said more details will be shared with impacted members during the course of January, including detailed statements and reconciliations.
