Western Gap Shortfall Cover

Western Gap Claim Form

Western Gap Claim Form 2022
  • Instructions and Uploads
  • Policyholder Details
  • Payment Instructions
  • Patient and Event Details
  • Declaration and Documents
0% Complete
1 of 5
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 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;
  • Your Medical Scheme option requiring you to pay a Co-Payment for Oncology Treatment;
  • You spend three days or more in a stepdown or recovery facility following a severe hospitalisation event;
  • The main member suffered a death, accidental death or total and permanent disability.
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. Should a portion of the documentation be received within the six month period, the Claim will be held pending for a further six month period, after which it will go stale and will not be honoured.
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
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.

PMB Claims

Claims flagged as Prescribed Minimum Benefit (PMB) medical procedures or claims with a high values may be investigated with your medical Scheme or discussed with your service provider. PMBs are a set of defined benefits that medical Schemes 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.

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.
Please direct all queries to the Kaelo Service Centre on 0861 008 258.

Claims can be e-mailed 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 seven to 14 working days.

Claims Checklist / Upload

Please note that your Claim cannot be assessed until you have submitted all the relevant documentation.

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

Tariff Shortfalls, Accidental Casualty, Oncology, Innovative Medicines, Co-Payment, Maternity Booster or Step-down Facility
Dental Reconstruction Benefit
Contribution Waiver and Accidental Death and Disability Benefit
Oncology-First Time Diagnosis

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.

Western Rethink Insurance
Please wait...