Gap cover claims can seem daunting at first, but the process is simple, and TRA, a trusted gap cover provider, is here to show you exactly how to navigate the gap cover claims process, ensuring you receive your reimbursement ASAP.
Is There One Process To Follow?
You need authorisation from your medical aid for them to cover your in-hospital treatment. Secondly, you have to ascertain that your gap cover provider can cover the shortfall on what your medical aid will pay to the respective practitioners or hospital should your medical aid not cover the full amount.
Gather and sign all the necessary paperwork and submit this to your gap cover provider. They will ensure the correct payments are made to you, so that you can then pay the provider/s.
Still unsure of the process? That’s fine! Your intermediary, if you have one, can be there to help you get all the information you need and advise you. They can explain the process step-by-step, as every gap cover provider may vary.
Some require email correspondence; others may use their own applications or deal directly with your medical aid. Some older providers may still accept documents via fax, though this is becoming less and less common.
TRA’s Claiming Process
With the TRA Gap Cover process, there are two ways in which a claim can be processed. These will suit different clients accordingly, being a manual process or an automatic process.
The manual process entails that you, as the policyholder, need to submit the following required documents. These documents may differ/ you may need more documents, depending on the type of claim. You can contact your intermediary or TRA directly (claims@totalrisksa.co.za , 011 371 1540) for more information, or visit our website, www.totalrisksa.co.za, and review the How to Claim documents.
- Claim form from the Service Provider
- First two (2) pages of the hospital account showing the admission and discharge dates of the hospital event
- The Medical Aid statement showing the payment of the Service Provider claim and the reason for the short payment
The automatic process entails that TRA will receive claims submitted by selected medical aid schemes on behalf of the policyholder. Should your medical aid company have such an agreement with TRA, the policyholder doesn’t need to submit their claim to TRA.
TRA will receive an electronic version of the claim and will process the said claim within seven (7) working days of receipt thereof. However, co-payment and sub-limit claims must still be submitted manually by the policyholder.
The Claiming Process: How To Go About It
When preparing to claim all expenses related to your gap cover, there are a few things to consider. This knowledge will help you navigate the claiming process more effectively and achieve the best possible outcome. The process starts with:
Understanding Your Gap Cover Policy
Prior to making a claim, it is recommended to familiarise yourself with the details of your gap cover policy. Review the applicable coverage limits, policy terms and conditions, waiting periods, and any exclusions that may apply.
Gather Required Documents
When submitting a claim, you will typically need to gather specific supporting documentation, including medical invoices, medical aid statements, and applicable gap cover policy details. You will also need to fill out a claim form to submit your gap cover claim. Keep a record of all documents you submit for your own reference.
Please note: Missing or incomplete documents are the leading cause of delays in gap cover claims, so double-check that you have everything before submitting. You need to prove that the treatment was authorised and that a shortfall exists.
Submitting a Claim
Once you have the necessary documentation, review the relevant claim submission requirements, complete any required forms and proceed to submit the claim. A fully completed claim form is essential to avoid delays in processing.
Important timing: Gap cover claims must be submitted within 6 months (180 days) from the procedure or treatment date. Most gap cover providers require claims to be submitted within 4 to 6 months of the medical event, so don’t delay.
You can submit your completed claim form and supporting documents via email or through the provider’s online portal. Simply open your browser and access the claims portal directly.
TRA’s claims avenues
With TRA, you can submit claims as above, via:
- Email – claims@totalrisksa.co.za
- The TRA Assist mobile app – see some more info here about the mobile app and TRA Assist services – https://totalrisksa.co.za/assist-service/
- The website – www.totalrisksa.co.za – click on SUBMIT A CLAIM
Claim Processing and Communication
After submitting your claim, the gap cover provider will review the documentation and process your claim. Claims are normally assessed on a case-by-case basis through a thorough assessment process, which may require reviewing documents more than once. The claims assessment period can take up to 14 days from receipt of all required documents.
You may be asked for additional documents during the claims assessment process, so keep your records accessible. TRA will communicate with you if any confirmation or further information is needed.
Reimbursement
If your claim has been approved, you will receive reimbursement for the eligible medical expenses. Once settled, the amount is subject to the limits and coverage specified in your gap cover policy and differs accordingly. The reimbursement amount will be paid directly to you, helping offset the out-of-pocket expenses incurred and easing the burden on your budget.
Seek Assistance if Needed
If you encounter any difficulties during the claiming process or have questions regarding your gap cover policy, don’t hesitate to contact your gap cover provider’s customer service team for support. They can provide guidance, answer your queries, and assist you in navigating the claim procedure effectively.
At the end of the day, claiming from gap cover should be a simple process. No one has the time nor wants to spend hours on the phone trying to submit a claim to a gap cover provider. Most providers will have a different way or process in order to claim from gap cover, so talk to your intermediary about the process that you need to follow in order to get your claim processed.
Why Might a Claim Be Denied?
Understanding why claims get rejected can help you avoid common pitfalls and delays:
- Unpaid premiums can result in the denial of a gap cover claim
- Missing or incomplete documentation delays processing and may lead to rejection
- Claims may be denied if the medical procedure resulted in a co-payment instead of a tariff shortfall — these are handled differently.
- Submitting outside the 180-day window means your claim won’t be processed
NB: SHOULD A CLAIM BE REJECTED FOR ADDITIONAL INFORMATION (E.G. PRE-AUTHORISATION LETTER, MEDICAL AID STATEMENT, DOCTOR’S ACCOUNT OR FIRST 2 PAGES OF THE HOSPITAL ACCOUNT) NOT RECEIVED, ALL THE ADDITIONAL INFORMATION MUST BE SUBMITTED TO TRA WITHIN 60 DAYS FROM THE DATE OF REQUEST OR THE CLAIM WILL BE REJECTED AS LATE/STALE IN TERMS OF THE POLICY, AND WILL NOT BE PAID.
