In order for a Claim to be valid, there are certain basic criteria that have to be met. These include, but are not limited to:
- Your contributions being paid up;
- You being a member of a valid South African Medical Scheme;
- You having been hospitalised (certain procedures such as an Endoscopic procedure, CT Scan and Chemotherapy does not require hospitalisation - Please refer to your Policy for the listed outpatient procedures that are covered);
- Your procedure not involving drug/alcohol rehabilitation or admission for depression or dental implants (please refer to the Policy for a full list of exclusions);
- Having obtained an authorisation number for the procedure from your Medical Scheme;
- Your Specialist, i.e. your surgeon or your anaesthetist, having charged a higher rate than your Medical Scheme reimbursement rate, i.e. you having a shortfall;
- Your Medical Scheme option requiring you to pay a Co-Payment or upfront Deductible (If a Benefit is provided), not related to the use of providers or authorisation/referral processes (unless a Benefit is provided);
- You receiving Accidental Emergency Treatment (as defined in the Policy) in a hospital casualty ward, and your Medical Scheme not covering this from the In-Hospital risk portion of your Medical Scheme;
- You having exceeded your limit for oncology Treatment, defined in your Policy;
- Your Medical Scheme option requiring you to pay a Co-Payment for oncology Treatment, defined in your Policy.
Once you have established that you have a valid Claim, you will be required to complete this Claim form.
Please note that this is not an automatic process, and you will be required to submit a separate Claim form to the Claim that has been submitted to your Medical Scheme.
When submitting the Claim form, you will also need to provide a copy of the relevant Specialists’ accounts, Hospital accounts and Medical Scheme statement showing the processing of the accounts and the shortfall. Please note that the Claim will not be processed until all documents have been received.
You have four months from the first day that you were hospitalised to submit your Claim and relevant documentation.
Any Claim received for the first time after the four month period has expired, will not be honoured. Should a portion of the documentation be received within the four month period, the Claim will be held pending for a further four month period, after which it will go stale and will not be honoured.
Please note that if you are a VAT registered vendor, this insurance claim settlement could potentially create a liability to pay output VAT to SARS i.t.o. S8 (8) of the VAT Act
Once received, your Claim will be processed and if all requirements have been met, the Benefit amount will be paid within seven to 14 working days.
Please direct all queries to the Kaelo Service Centre on 0861 493 587.