Discovery Health vs Medihelp

Both Discovery Health and Medihelp are registered with the Council for Medical Schemes and are bound by the Medical Schemes Act 131 of 1998. That means both must cover Prescribed Minimum Benefits in full at the prescribed level of care — emergency conditions, the listed diagnosis and treatment pairs, and the 26 Chronic Disease List conditions — regardless of which option a member has chosen.

Both also operate an internal dispute process, and a member who is unhappy with the outcome can escalate to the Council for Medical Schemes.

• Networks. Each scheme contracts its own designated service providers, so the same hospital can be in-network on one scheme and out-of-network on the other.
• Reimbursement rate. Each scheme publishes its own rate, which determines whether a provider’s account leaves you with a shortfall.
• Option structure. Savings-based, network-based and hospital-only options behave very differently when a day-to-day claim is submitted.
• Chronic management. Registration processes, formularies and designated pharmacies differ, and are a frequent source of rejected medicine claims on both schemes.

Comparison tables rarely predict what actually happens when you claim. The practical questions are: is your usual hospital and specialist in the option’s network, is your chronic medicine on that scheme’s formulary, and how does the scheme handle Prescribed Minimum Benefit treatment when a limit runs out. Those three answers explain most rejected claims on either scheme.