Dis-Chem Gap Claim Pre – Screen Questionnaire

We understand that claiming from your Dis-Chem Gap policy may feel overwhelming, so we’ve put together a quick questionnaire to guide you through the Claims process.

In-hospital
Before you start completing your online Claim form, please remember we are going to need supporting documents which you will upload towards the end of the process. Make sure you have the below on hand, for a hassle-free claim:

• Hospital invoice including admission and discharge date.
• Doctor/Specialist account.
• Medical aid statement showing shortfalls and rejection codes/reasons.

Accidental
Before you start completing your online Claim form please remember we are going to need supporting documents which you will upload towards the end of the process. Make sure you have the below on hand, for a hassle-free claim:

• Claim form (online)
• Facility invoice (from the Hospital)
• Doctor's account

According to your Dis-Chem Gap policy rules, this benefit is payable if your child dependant is under age 12, please refer to the below extract from the Policy.

Casualty Child Illness
Benefits will only be paid in respect of emergency outpatient services that are provided within a casualty ward of a Hospital.

The Benefit is only payable in the event of after-hours treatment in an Emergency situation. After-hours are Mondays to Fridays between 18:00 and 08:00 and all day Saturdays, Sundays and South African public holidays.
The Benefit payable is equal to the total cost of treatment less the amount paid by your Medical Scheme from your hospital/risk benefit. If payment is made from your available Medical Savings Account, or from your own pocket, we will refund that too.

Subject to two events Per Annum and a maximum of R2 860 per event.
The Benefit only applies to children under age 12.

To proceed with your claim please continue to complete this form and upload your supporting documents. You can also contact your broker for advice.

Before you start completing your online Claim form please remember we are going to need supporting documents which you will upload towards the end of the process. Make sure you have the below on hand for a hassle-free claim:

• Claim form (on-line),
• Facility invoice (from the Hospital)
• Doctor's account.

According to your Dis-Chem Gap policy rules, this benefit is payable if treatment takes place after-hours as defined in your Policy. Please refer to the below extract from the Policy

Casualty Child Illness
Benefits will only be paid in respect of emergency outpatient services that are provided within a casualty ward of a Hospital.

The Benefit is only payable in the event of after-hours treatment in an Emergency situation. After-hours are Mondays to Fridays between 18:00 and 08:00 and all day Saturdays, Sundays and South African public holidays.
The Benefit payable is equal to the total cost of treatment less the amount paid by your Medical Scheme from your hospital/risk benefit. If payment is made from your available Medical Savings Account, or from your own pocket, we will refund that too.

Subject to two events Per Annum and a maximum of R2 860 per event.
The Benefit only applies to children under age 12.

To proceed with your claim please continue to complete this form and upload your supporting documents. You can also contact your broker for advice.

According to your Dis-Chem Gap policy rules, this benefit is not payable if the patient is over the age of 12, please refer to the below extract from the Policy.

Casualty Child Illness
Benefits will only be paid in respect of emergency outpatient services that are provided within a casualty ward of a Hospital.

The Benefit is only payable in the event of after-hours treatment in an Emergency situation. After-hours are Mondays to Fridays between 18:00 and 08:00 and all day Saturdays, Sundays and South African public holidays.
The Benefit payable is equal to the total cost of treatment less the amount paid by your Medical Scheme from your hospital/risk benefit. If payment is made from your available Medical Savings Account, or from your own pocket, we will refund that too.

Subject to two events Per Annum and a maximum of R2 860 per event.
The Benefit only applies to children under age 12.

To proceed with your claim please continue to complete this form and upload your supporting documents. You can also contact your broker for advice.

Before you start completing your online Claim form please remember we are going to need supporting documents which you will upload towards the end of the process. Make sure you have the below on hand for a hassle-free claim:

• Claim form (online),
• Medical Scheme statement showing shortfalls and rejection codes,
• Specialist/Doctor’s account.

According to your Dis-Chem Gap policy rules, this benefit is payable if the treatment is paid for from the risk/hospital benefit of your Medical Scheme, please refer to the below extract from the Policy:

Out-of-Hospital Tariff Shortfalls

This Benefit provides additional cover of up to 500% of the Medical Scheme rate for outpatient procedures, subject to the costs being funded from the risk/hospital benefit by the Insured Party’s Medical Scheme.

The Benefit provided is for charges above the Medical Scheme Tariff, limited to five times (500%) of the Medical Scheme Tariff, and subject to the Overall Annual Limit.

To proceed with your claim please continue to complete this form and upload your supporting documents. You can also contact your broker for advice.

Before you start completing your online Claim form please remember we are going to need supporting documents which you will upload towards the end of the process. Make sure you have the below on hand for a hassle-free claim:

• Claim form (online),
• Medical aid statement showing shortfalls and rejection codes / reasons,
• Hospital invoice if treatment took place in hospital,
• Specialist/Doctor’s account (If this co-payment was payable to the Doctor/Specialist).

In order for us to assess your Claim without any delays, please ensure you have the following documents:

Claims Checklist	Where to get it?	Shortfalls	Family Booster	Hospital Booster	Family Protector	Contribution Waiver
Claim Form
Hospital Account (not statement)	Hospital
Doctor account (not quote)
Medical aid statement (including rejection reasons)	Medical Aid
Death Certificate
Accident report (if reported to SAPS)
Letter confirming expected vs actual delivery date	Medical Doctor