KaeloGap Claim Form

KaeloGap Claim Form 2022
  • Instructions
  • Policyholder Details
  • Payment Instructions
  • Patient and Event Details
  • Declaration
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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 premiums being paid up;
  • You being a member of a valid South African Medical Scheme;
  • You having been hospitalised (certain procedures such as a Gastroscopy or Colonoscopy procedure, CT Scan and Chemotherapy does not require hospitalisation - Please refer to your Policy for the listed outpatient procedures that are covered);
  • 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 (This will only apply if your Kaelo Gap cover option includes a benefit for Co-payments & deductibles ). This excludes penalty co-payments applied by your medical scheme for the use of a Non- Network hospital (unless your Kaelo Gap option includes this as a specified benefit);
  • You receiving Accidental Emergency Treatment (as defined in the Policy) in a hospital casualty ward where there is a difference between the total cost of treatment and the amount paid by the Medical Scheme from your hospital/risk benefit. If payment is made from your available Medical Savings account, or from your own pocket, this portion will be reimbursed;
  • 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 six 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 six month period has expired, 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.
Claims are assessed on a line by line basis. Each line has a code on your healthcare or service provider’s account and this accounts for the total amount charged.
These codes describe the medical procedure that was performed or the service that was provided.
Your medical aid must pay a portion of the cost of a coded line from your hospital or risk benefit in order for that claim line shortfall to be covered by your Gap cover unless you are claiming for a benefit with different qualifying criteria such as a Family protector or a defined co-payment.Claims can be e-mailed to kaelogap@kaelo.co.za.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.

PMB Claims
Claims flagged as Prescribed Minimum Benefit (PMB) medical procedures or claims with high values may be investigated with your medical aid or discussed with your service provider. PMBs are a set of defined benefits that medical aids are required to cover by law. This means that as a medical aid member, you shouldn’t incur any out-of-pocket medical expenses related to a PMB.

Processing of insurance information is done in accordance with applicable legislation, as well as our Privacy Policy which can be found in our Compliance and Trust Centre on our website: www.kaelo.co.za and www.centriq.co.za

Claims Checklist / Upload

In order for us to assess your Claim without any delays, please ensure you have the following documents:
Tariff Shortfalls, Accidental Casualty, Child Illness Casualty, Co-payments and Deductibles, Oncology Co-payments and Deductibles, Oncology Co-payments and Deductibles, Oncology Sub-limits and Innovative Medicines
Contribution Waiver and Family Protector
Family Booster
Hospital Booster
Dental Reconstruction Benefit
File Upload *
Maximum upload size: 33.55MB
If you would like to make use of our RAF assistance benefit kindly email kaelogap@kaelo.co.za with your accident details and we will put you in touch with our service provider.

This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme. This Policy is not a substitute for Medical Scheme membership.

Kaelo Risk (Pty) Ltd is an authorised financial services provider (FSP 36931).
Underwritten by Centriq Insurance Company Limited (“Centriq”), a licensed non-life insurer and authorised Financial Services Provider (FSP 3417).

Centriq Insurance
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