Getting screwed by over the counter medication

We realised that we have just hit our medical aid self-payment gap all of 2 and a half months into the year. It sounded completely wrong so we checked our records and it turns out a substantial portion of the amounts pharmacists submitted to Discovery was for over the counter medication which included our baby’s inoculations. My wife also pointed out that the over the counter stuff effectively extended our self-payment gap too. I thought about this for a bit and realised that we are effectively being double charged for over the counter stuff submitted to medical aid.

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Here is a hypothetical scenario:

  • Medical savings balance: R5 000;
  • Over the counter medication submitted to and paid by medical aid: R2 500;
  • Original self-payment gap: R5 000.

What seems to be happening here is that the over the counter submissions are deducted from savings and paid by the medical aid. So that is R2 500 less than we would have had available if we had paid cash for that medication instead. Fair enough, except what happens next is that the over the counter submissions of R2 500 is effectively added to the original self-payment gap, extending that self-payment gap to R7 500. Of course the self-payment gap is that amount you fund out of your pocket before the above threshold portion of your cover kicks in and covers some of your medical costs.

So, as I understand this, we pay R2 500 out of our savings because the pharmacists just submitted the charges to our medical aid (it also bothers us that our baby’s inoculations were considered over the counter – they probably account for a substantial portion of the over the counter submissions). We would have had to pay cash for that stuff anyway, had it not been submitted. At this point we have basically paid for the over the counter stuff, Discovery just paid it on our behalf and recovered the money from our savings.

Now, once we exhaust our savings, largely due to these over the counter charges, we find that Discovery has added the over the counter charge to our self-payment gap which means that we have to pay an additional R2 500 of medical expenses ourselves, in addition to the R5 000 self-payment gap we had originally. That is a double charge. We paid for the over the counter stuff when it was deducted from our savings and now we have to cover that amount again as part of an expanded self-payment gap. We could have saved ourselves R2 500 if we were just paying for our routine medical stuff ourselves.

Am I missing something? This seems like a bit of a problem in how medical aids work.

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