Medical scheme activist Angela Drescher first came to the attention of the public in February this year, when she testified at hearings held as part of the Competition Commission’s inquiry into the private healthcare market.

She disclosed intimate details of her family’s health challenges and how she had fought to get Discovery Health Medical Scheme (DHMS) to follow the correct treatment protocols.

Championing her family’s cause had forced her to educate herself about the Medical Schemes Act and the prescribed minimum benefit (PMB) regulations, Drescher says.

She joined a social media group started by disgruntled medical scheme members and found that she was able to help them. She currently helps members with claims against DHMS.

Earlier this month, Drescher received a response from the Council for Medical Schemes (CMS) about 19 complaints she had lodged against DHMS or its administrator, Discovery Health.

By the time the complaints were brought to the council’s attention, most of them had been resolved, some in favour of the members, Drescher says. The CMS has asked for more information so that some of the outstanding issues can be resolved.

“Despite being escalated, sometimes for many months, some member complaints remain unresolved by either the administrator, Discovery Health, or scheme executives,” Drescher says.

She recently reported that Discovery Health’s call centre had been providing members with incorrect information, after a member, Pauline Mendes, was told that DHMS would pay in full for the treatment of her son’s fractured tibia only if he was admitted to hospital. Drescher says this was not consistent with the Medical Schemes Act or its regulations.

She “tested the system” by making a number of calls to the call centre, asking what protocol would be followed if an emergency were not treated in a hospital. She found that at least eight call-centre agents repeated the incorrect information provided to Mendes. With Drescher’s help, Discovery Health agreed to pay for Mendes’s son’s procedure in full.

Mendes was also told by a call-centre agent that “fractures of all limbs (other than fingers and toes) are regarded as emergency PMBs and are paid from the risk pool at full cost for the first 24 hours. Thereafter, normal designated service provider rules apply.” Drescher says this is an example of the incorrect information provided by Discovery Health.

Drescher says the administrator has described the mistakes as “one-off errors”, but she believes they are more pervasive.

Dr Jonathan Broomberg, the chief executive of Discovery Health, says the administrator has embarked on a campaign to educate its call-centre staff about the statutory definition of an emergency and the importance of communicating accurately to members who ask questions about this issue.

“While, generally, an emergency medical condition will require a hospital admission, this clearly does not apply to every situation,” he says.

He says Drescher helps a small number of DHMS members whose claims have been rejected.

The administrator processes hundreds of millions of claims a year, and more than 99 percent of these are paid accurately, he says. It handles 40 000 calls a day, and the vast majority of them are dealt with accurately, Broomberg says.

“There are errors, and some of these find their way to [Drescher], but to describe them as pervasive is unfair,” Broomberg says.