Western Gap Claim Form

Western Gap Claim Form 2023

Instructions
OTP Validation
Policyholder Details
Payment Instructions
Patient and Event Details
Declaration

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	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.
	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 service provider’s account that accumulates to the total amount charged. Your medical aid must pay a portion of the cost per line from your hospital benefit in order for that claim line shortfall to be reviewed by your Gap cover.
	Claims flagged as Prescribed Minimum Benefit (PMB) 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.westnat.com.
	When submitting the Claim form, you will need to provide supporting documents as detailed below in the checklist. Claims can be emailed to western@kaelo.co.za. Once received, your Claim will be processed and if all requirements have been met, the Benefit amount will be paid within 7 to 14 working days. Please direct all queries to the Kaelo Service Centre on 0861 008 258. Click here to view the Claims Journey.
	Please note that if you are a VAT registered vendor and the loss was incurred in furtherance of your enterprise, this insurance claim settlement could potentially create a liability to pay output VAT to SARS i.t.o. S8 (8) of the VAT Act.

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 & Co-payments	Oncology First Time Diagnosis	Maternity Booster	Step Down Facility	Contribution Waiver / Accidental Death & Disability
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)
Step Down Facility Account	Step Down Facility
Medical Reports	Oncologist
Histology Reports	Pathologist or Oncologist

Please enter your ID, Passport No. or your Western Gap Policy No. in order for us to find your policy.

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South African ID Number

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Cellphone No.

Please ensure you enter the cellphone number that is linked to your policy. You will receive a OTP to verify your policy and continue with the online submission for your claim.

Western Gap Product Name

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OR Download Offline Form

Kaelo Risk (Pty) Ltd is an authorised financial services provider (FSP 36931).
This product is underwritten by Western National Insurance Company Limited (FSP 9465).

Statutory notice:

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.