Discovery Health Medical Scheme

Every Discovery Health plan covers the diagnosis, treatment and care of an emergency medical condition, a defined list of 271 diagnoses and a defined list of 27 chronic conditions. Three conditions attach to that cover, and they are where members get caught:

• Your condition must be on the PMB list and the treatment must match the treatment in the defined benefit.
• You must use a designated service provider in the Discovery network. This does not apply in an emergency, but once your condition has stabilised the scheme may transfer you to a network hospital or provider.
• If your treatment does not meet those criteria, Discovery pays 80% of the Discovery Health Rate and you are responsible for the rest.

Above the statutory 27, the Executive Plan and Classic Comprehensive add conditions from Discovery's own Additional Disease List. Every other plan in the range stops at the 27.

Chronic medicine

• Executive and the Comprehensive plans: approved medicine on the Discovery medicine list is covered in full at a network provider. On Executive and Classic Comprehensive this full cover does not extend to Additional Disease List conditions.
• Priority, Saver and Core: covered in full at a MedXpress Network Pharmacy. Off-list medicine is paid up to 100% of the DHR or the generic reference price, capped at the monthly Chronic Drug Amount.
• Smart Saver and Smart: off-list medicine is covered only up to the therapeutic reference price of the equivalent medicine or group of medicines.
• KeyCare Plus and KeyCare Core: covered in full at a network pharmacy or through your nominated KeyCare Network GP, who must be the one to prescribe it.
• KeyCare Start: the plan comparison records chronic medicine as being covered in a state facility. KeyCare Start Regional is recorded as covered at network pharmacies or through the nominated Regional Network GP.

New for 2026 on KeyCare: if you are registered on the relevant Care Programme you keep full cover at 100% of the DHR for the approved basket of care. If you are not registered, cover drops to 80% of the DHR and you pay the co-payment. It applies to major depression as a PMB and to diabetes, hypertension, hyperlipidemia, ischaemic heart disease and HIV.

Day-to-day money on a Discovery plan comes from up to four places, and most plans have only one or two of them.

1. Medical Savings Account. Your own money, paid in advance, on 12 of the 25 plans. Between 7% and 25% of your contribution depending on the plan. Amounts are in the rates section above.
2. Personal Health Fund. Risk money you have to earn by activating Personal Health Pathways and completing recommended actions. Discovery says more than 390 000 members activated a pathway in the first nine months.
3. Day-to-day Extender Benefit. Kicks in when savings run out, on Executive, Classic Comprehensive, Priority, Saver and Smart Saver. It covers pharmacy clinic consultations in the wellness network, video call consultations with a network GP, referred consultations with a network GP who meets the digital criteria, and kids casualty visits.
4. Above Threshold Benefit. Only on Executive, Comprehensive and Priority, and only once your claims reach the Annual Threshold.

How the Personal Health Fund works in 2026

• Advance on 1 January. R1 000 per adult (R500 on KeyCare) if you activated Personal Health Pathways, enabled physical activity and sleep tracking, and completed your Health Check in the previous year.
• Completing actions. R500 per recommended action, up to R3 000 per adult and R1 500 per child on the top plans. Once you run out of actions you can earn R100 a week for closing either your exercise or your sleep ring.
• Unlocking the child allocation. Every adult on the policy has to complete at least two recommended actions before the fund for beneficiaries under 18 is released.
• Personal Health Challenges. New for 2026. Six challenges across three categories, running 5 or 10 weeks. Completing one adds up to R1 500 per adult, up to R3 000 an adult a year, on top of the annual limit.

The Personal Health Fund is spent before your Medical Savings Account, so it preserves your savings rather than topping them up. Discovery also says members joining for 2026 can double the limits above.

The maternity benefit is activated, not automatic, and runs until two years after the birth. Executive and the Comprehensive plans get 12 antenatal consultations with a gynaecologist, GP or midwife. Priority, Saver, Smart Saver, Smart and Core get 8. On Active Smart and every KeyCare plan, maternity care comes out of the plan's ordinary day-to-day benefits instead.

On the plans that carry the benefit, you also get:

• Two 2D ultrasound scans, or one 2D scan and one nuchal translucency test. 3D and 4D scans are paid at the 2D rate.
• One chromosome test or Non-Invasive Prenatal Test if you meet the clinical entry criteria.
• A defined basket of blood tests.
• Private ward cover up to R2 800 a day for the delivery on Executive and the Comprehensive plans.
• Up to two visits for your baby to a GP, paediatrician or ENT after the birth.
• One six-week post-birth consultation with your midwife, GP or gynaecologist.
• Five antenatal or postnatal classes or consultations with a registered nurse, up to two years after the birth.
• One nutritional assessment with a dietitian, two mental health consultations with a counsellor or psychologist, and one breastfeeding consultation.
• On Executive, R6 500 for essential registered devices with a 25% co-payment.

Nurture at Home, new for 2026

If your newborn spends 7 or more days in a Neonatal Intensive Care Unit, the scheme funds a basket of support after discharge: a pre-discharge overnight stay in hospital for one registered parent, virtual health coaching, a virtual and a home nurse visit, mental health support and follow-up paediatrician visits. It is available on every plan except Essential Smart, Essential Dynamic Smart, Active Smart and the KeyCare plans, and it is subject to clinical entry criteria.

Discovery has also added perinatal bereavement counselling for pregnancy loss, stillbirth or the loss of a baby immediately after birth, accessed through the Women's Health Hub.

Assisted Reproductive Therapy is available only on Executive and the Comprehensive plans: up to two cycles, a limit of R140 000 a person a year paid at 75% of the DHR with a 25% co-payment, including egg-donated cycles. Members on the Oncology Programme who meet the criteria get egg and sperm cryopreservation for up to five years.

Cancer cover comes in three layers on a Discovery plan, and the middle layer changed for 2026 in a way that costs members money.

What changed in 2026. The Oncology Innovation Benefit co-payment now applies to all molecules and all conditions, at 50% for the Comprehensive Series and 30% for the Executive Plan. It applies only to new treatment plans approved from 2026 onwards, so members already on a treatment plan keep their 2025 co-payment level. Discovery says the benefit has covered nearly R1 billion in treatment since 2019 and grew from 7 molecules and 2 conditions to 11 molecules and 20 conditions by 2025, with annual growth in claimants and costs above 45%.

On KeyCare, cancer cover is Prescribed Minimum Benefits only: in the Discovery network on KeyCare Plus and KeyCare Core, and in a state facility on KeyCare Start and KeyCare Start Regional. On Active Smart it is PMB only, in the network.

For 2026 the oncology basket of care adds cover for a palliative care consultation, and Discovery has introduced designated service providers for oncology on certain plans.

Discovery's mental health cover is delivered through programmes rather than a rand limit, and the plan comparison does not publish an out-of-hospital psychology limit for any plan.

• Mental Wellbeing Care. Members identified with moderate to severe depression symptoms after a mental wellbeing assessment get a virtual or face-to-face consultation with a Premier Plus GP or network psychologist, coaching sessions with a social worker, two dietitian consultations and a clinically appropriate digital mental wellbeing course. Clinical entry criteria apply.
• Care Programmes. Preventative and condition-specific programmes for mental health, diabetes, HIV and heart conditions. You must register on the programme to unlock the additional benefits.
• Digital Mental Health. An on-demand platform. If you are diagnosed with depression, claims fund from your PMBs or the Mental Health Care Programme if you are enrolled. If you do not meet the criteria or have used those benefits, claims come from your available day-to-day benefits.
• Trauma Recovery Extender Benefit. Extends out-of-hospital cover after certain traumatic events for the rest of that year and the following year, and gives you and your dependants six counselling sessions per person per year with a psychologist, clinical social worker or registered counsellor.
• Perinatal bereavement counselling after pregnancy loss, stillbirth or the loss of a baby immediately after birth.
• A mental wellbeing assessment is part of the Screening and Prevention Benefit, once a year, on every plan.

Sleep disorders, new for 2026

Discovery has added risk-funded cover for insomnia and obstructive sleep apnoea. It uses the Vitality Sleep Score to flag members at risk, offers them a sleep assessment as a recommended action, and then funds a diagnostic consultation with a Premier Plus GP or network psychologist, sleep health coaching for those at highest risk, and internet-based cognitive behavioural therapy for insomnia. CPAP for sleep apnoea continues to be funded from the Medical Savings Account, which means it is not available on the plans with no MSA.

This is the weakest documented area of the 2026 range. Only the Smart Saver, Smart and KeyCare plans have a named dentistry and optometry benefit in the plan comparison. On Executive, Comprehensive, Priority, Saver and Core, dentistry and optometry are simply day-to-day claims funded from the Medical Savings Account, then the Day-to-day Extender Benefit, then the Above Threshold Benefit where one exists. No separate rand limit for either is published in the 2026 contribution table or plan comparison.

The dental check-up on Smart Saver includes a polish and fluoride application and can be done at any dentist, not just a network one. The eye test must be at a network optometrist.

The Screening and Prevention Benefit is on every plan in the range, including KeyCare. It covers:

• A health check at a wellness network provider: blood glucose, blood pressure, cholesterol and body mass index.
• A mammogram every two years.
• A Pap smear every three years, or one HPV test every five years.
• A mental wellbeing assessment every year.
• A PSA prostate screening test once a year.
• HIV screening tests.
• Seasonal flu vaccine during pregnancy, or for members 65 and over, or for members registered for certain chronic conditions.
• Pneumococcal vaccine for members over 65 or registered for certain chronic conditions, on a doctor's prescription.
• Bowel cancer screening every two years for members between 45 and 75.
• Kids screening: weight, height, body mass index and blood pressure at a wellness provider.

More frequent screening is available if you meet the clinical criteria. Consultations that are not PMBs are paid from your available day-to-day benefits, which on a Core or Smart plan means from your own pocket.

Other benefits that run across most of the range: the Advanced Illness Benefit, with unlimited cover for approved palliative care at home, care coordination, counselling and supportive end-of-life services; the WHO Global Outbreak Benefit for outbreaks recognised by the World Health Organisation; the Home Monitoring Device Benefit at up to R4 850 a person a year at 100% of the DHR; point-of-care medical devices at up to 75% of the DHR; and home-based virtual care for members 65 and over identified as high risk, offering a virtual consultation instead of a casualty visit.

These documents are a summary of key benefits and features, and the scheme states that the Discovery Health Medical Scheme Rules prevail in every instance. The following are not in the 2026 product information brochure, contribution table or plan comparison, so treat anything you read elsewhere as unverified until the scheme confirms it in writing:

• Waiting periods. No general or condition-specific waiting period is published in any of the three 2026 documents.
• Late-joiner penalties. No penalty percentages or bands are published.
• The full list of general exclusions.
• Rand limits for dentistry, optometry, physiotherapy, psychology and external appliances on the Executive, Comprehensive, Priority, Saver and Core plans.
• The fixed co-payment amounts for the GP, dental and optometry benefits on Classic Smart and Essential Smart.
• The list of hospitals in the Smart, Dynamic Smart, Delta, Coastal and KeyCare networks.
• The Chronic Drug Amount, the Discovery medicine list and the Additional Disease List.
• The defined list of procedures that triggers the R5 000 to R23 700 upfront payment on Classic Priority.

Three exclusions are named. Cochlear implants are excluded on Essential Smart, Essential Dynamic Smart, Active Smart and the KeyCare plans. Bone-anchored hearing aids and processor upgrades are excluded on the KeyCare series, Essential Smart, Essential Dynamic Smart and Active Smart. Joint replacements are covered as PMB only on those same plans. Pre-existing conditions are excluded from both the International Travel Benefit and the Africa Evacuation Benefit.

• The increase was deferred. January to March 2026 ran at 2025 contribution rates and 2025 monthly savings allocations. The rates on this page apply from 1 April 2026 to 31 December 2026.
• Join after January and you get less. Your Medical Savings Account, Annual Threshold and Above Threshold Benefit are all calculated on the remaining months of the year, not the full year.
• Three children, then free. Discovery counts a maximum of three children when working out your contribution, your annual savings account and your threshold amounts. The exception is a child placed in your custody, such as foster care, where every child on the membership counts.
• New members can double the Personal Health Fund. Discovery states that members joining the Scheme for 2026 can double their published Personal Health Fund limit.
• Income verification on KeyCare. The lower KeyCare bands are verified. Income means the higher of the main member's or the registered spouse or partner's earnings, commission and employment rewards, plus interest from investments, income from leasing assets or property, distributions from a trust, pension or provident fund, and any statutory social assistance received.
• Shariah compliant arrangement is available on all health plans.

• Pre-authorisation. Hospital pre-authorisation runs through the same line as general queries, 0860 99 88 77, open 07:00 to 20:00 Monday to Friday and 08:00 to 13:00 on Saturdays. Planned admissions on the network plans need to be authorised before you go, because the upfront payment is charged by the hospital, not deducted afterwards.
• Ask Discovery. On Essential Dynamic Smart and Active Smart, admission to the Dynamic Smart Hospital Network is by referral through Ask Discovery or the home-based care designated service provider.
• Claims. Email claims to claims@discovery.co.za or post to PO Box 784262, Sandton, 2146. Turnaround times are not published in these documents.
• Chronic Illness Benefit registration. Application forms go to CIB_APP_FORMS@discovery.co.za or PO Box 652919, Benmore, 2010. Register before you claim, and on KeyCare register on the Care Programme too or your cover drops to 80% of the DHR.
• The DSP rule is the one that costs money. For Prescribed Minimum Benefits you must use a designated service provider. If you do not, or the treatment does not match the defined benefit, Discovery pays 80% of the Discovery Health Rate and the rest is yours. In a genuine emergency the rule does not apply, but once you are stable the scheme may move you to a network facility.
• Home-based care. If a healthcare provider recommends Hospital at Home and you decline it, an upfront deductible of R5 450 applies to the admission.

Discovery publishes a four-step process in the 2026 plan comparison. Work through it in order, because the Council will ask whether you have.

1. Complete the online complaints form on discovery.co.za, once you have already contacted the scheme and feel the query is unresolved.
2. Escalate to the Principal Officer of Discovery Health Medical Scheme, by the online form or by email to principalofficer@discovery.co.za.
3. Lodge a formal dispute if you have a final decision from the scheme and want to challenge it. The dispute process is on the scheme's website.
4. Take it to the Council for Medical Schemes. You may contact the Council at any stage, though the scheme asks you to try the first three steps first. Complaints Unit, Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion 0157. Phone 0861 123 267 or email complaints@medicalschemes.co.za.

The weighted average increase was 7.2%, but it was deferred to 1 April 2026. Members on 65% of the book got 6.9%, the other 35% got 7.9%, and Active Smart members got 0%. Because January to March ran at 2025 rates, Discovery values the deferral at R1.5 billion across the scheme, or about R1 100 per policy.

Because the increase started on 1 April rather than 1 January. Your monthly Medical Savings Account allocation stepped up on the same date. This is also why the annual savings account figures Discovery publishes do not equal twelve times the monthly amount: the first three months of 2026 were paid at the 2025 rate.

KeyCare Start Regional at R1 278 a month for a main member, but only if your household income is R10 950 or less. Discovery verifies income on the lower KeyCare bands. If you do not qualify by income, the cheapest plan is Active Smart at R1 350 a month, which has flat pricing, no savings account, no out-of-hospital scan benefit, PMB-only cancer cover and a R7 750 upfront payment on any planned admission.

Classic pays specialists at 200% of the Discovery Health Rate. Essential and Coastal pay 100%. Delta means a reduced hospital network with a R11 100 upfront payment outside it, in exchange for roughly 20% off the contribution. Smart means the Smart Hospital Network with a R12 650 upfront payment outside it. Coastal means you are covered in approved private hospitals in the four coastal provinces only, and outside them Discovery pays 70% of the DHR on the hospital account.

Because Discovery pays at a set rate, the Discovery Health Rate, and not at whatever a practitioner charges. Specialists Discovery has a payment arrangement with are covered in full on every plan. Specialists without one are paid at 300% of the DHR on Executive, 200% on the Classic plans and 100% on the Essential, Coastal and KeyCare plans. Radiology and pathology are paid at 100% of the DHR on every single plan. Ask the surgeon and the anaesthetist what rate they bill at, and ask Discovery whether they are in arrangement, before an elective admission.

No, you earn it. You have to activate Personal Health Pathways, enable physical activity and sleep tracking, complete a Health Check and work through recommended actions at R500 each. Every adult on the policy must complete at least two actions before the children's allocation is released. Completing a Personal Health Challenge adds up to R1 500 an adult, capped at R3 000 an adult a year. The maximum is R12 000 a policy plus R12 000 in challenge boosts on the top plans, and R1 000 on KeyCare. It is spent before your Medical Savings Account.

Up to a limit, then it drops. Executive and Classic Comprehensive cover the first R500 000 of approved treatment over a 12-month cycle in full, Classic Smart Comprehensive R375 000, and the Priority, Saver, Smart Saver, Smart and Core plans R250 000. Above that, cover falls to 80% of the DHR, except on Executive and Classic Comprehensive where the Extended Oncology Benefit continues in full for a defined list of cancers. PMB treatment costs count towards the limit. On Active Smart and every KeyCare plan, cancer cover is Prescribed Minimum Benefits only.

Only Executive, the two Comprehensive plans and the two Priority plans. The threshold is R42 570 on Executive, R34 810 on Comprehensive and R27 160 on Priority for a main member. Once your day-to-day claims reach it, the scheme pays day-to-day claims again, unlimited on Executive and up to R36 290, R31 100 or R20 080 on the others. The Saver, Smart Saver, Smart, Core and KeyCare plans have no threshold at all.

Classic Smart, on the numbers. Essential Smart charges every beneficiary R2 161, so a couple with two children pays R8 644 a month. Classic Smart charges R3 018 for the main member, R2 381 for an adult and R1 205 a child, which comes to R7 809 for the same family. Classic Smart also pays specialists at 200% of the DHR rather than 100%. The flat-priced Smart plans only make sense for single members and couples.

On most plans, yes. The International Travel Benefit covers up to R5 million per person per journey for emergency medical costs for 90 days from departure, rising to $1 million a journey on the Executive Plan. Pre-existing conditions are excluded and specific rules apply. No KeyCare plan has the benefit, and no KeyCare plan has the Africa Evacuation Benefit either. Planned treatment overseas is a separate benefit, available only on Executive at R750 000 and the Comprehensive plans at R500 000, both with a 20% co-payment.

Discovery does not publish them. The 2026 product information brochure, contribution table and plan comparison say nothing about general or condition-specific waiting periods or late-joiner penalties. The Medical Schemes Act allows an open scheme to apply a general waiting period of up to 3 months, a condition-specific waiting period of up to 12 months on a pre-existing condition, and a permanent late-joiner penalty of up to 75%. Ask the scheme in writing what it will apply to you, and check the counter-offer before you sign it.

Four steps. Complete the online complaints form on discovery.co.za. If that fails, escalate to the Principal Officer at principalofficer@discovery.co.za. If you have a final decision and want to challenge it, lodge a formal dispute using the process on the scheme's website. At any stage you can go to the Council for Medical Schemes on 0861 123 267 or complaints@medicalschemes.co.za, though the scheme asks you to work through the first three steps first.