Discovery Health asks members to repay thousands after claims processing error

Discovery Health has sent communication to a number of members requesting them to repay Discovery Health Medical Scheme (DHMS) after a processing error saw claims incorrectly paid out at a higher rate than their plan’s benefits allow.

The error is related to the Above Threshold Benefit (ATB) on the Executive, Classic Comprehensive, Classic Smart Comprehensive, Classic Priority and Essential Priority plans.

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Day-to-day expenses are paid from the ATB once the member has reached their annual threshold. However, the ATB itself has limits – and when these were reached, Discovery Health paid for subsequent claims even though these claims should have either been paid from a member’s medical savings account (MSA) or funded by the member.

Discovery Health won’t disclose the number of impacted members or the quantum of the total amount owed but says a “small proportion of scheme members” and “only certain members” on the five plans were affected.

The two largest affected plans (Classic Comprehensive and Classic Priority) had an average number of members of 91 370 and 67 353 in 2024 respectively. When it comes to beneficiaries, the average was 183 863 and 144 481 respectively.

The three other plans are far smaller with average members of 7 260 (Executive), 4 667 (Essential Priority) and 3 157 (Classic Smart Comprehensive).

Moneyweb understands that the number of impacted members is less than 1% of the DHMS scheme (which has 1.35 million members and 2.7 million beneficiaries).

Read: Discovery forecasts up to 32% jump in annual earnings

As the contracted administrator of DHMS, Discovery Health has reprocessed these claims (originally processed between January and December 2025) correctly and has been in touch with affected members.

‘You now owe the scheme’

In these letters, Discovery Health says: “When we reprocessed these claims, some would have incurred a co-payment at the time of claiming but did not because of the error.

“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.”

Moneyweb has seen communication to members where they owe the scheme as much as R22 000, R25 000 and R37 000.

At current rates (contributions for 2026 have been frozen at 2025 levels until 31 March), contributions for a main member on Classic Comprehensive and Classic Priority total R83 700 and R52 176 respectively.

Read: Discovery to hike top, low-end medical aid plans by 7.9% in 2026

Affected members have received statements showing the amount they owe the scheme.

Discovery says: “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” … and that it is “committed to working with you to agree a repayment plan that works for you and the scheme.”

Discovery Health says it recognises “that unexpected adjustments can affect personal budgets and planning”.

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It says 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.”

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.”

Read: Top 10 Discovery medical claims paid in 2024 totalled R70m

It adds that members’ 2026 medical benefits and medical aid cover and access “are entirely unaffected by this error” and no healthcare providers have been negatively impacted. The latter would be obvious as all claims were paid.

Discovery Health says “stronger controls have been implemented to prevent a recurrence” and that “claims processing systems are functioning entirely correctly”.

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