Claiming should be a simple process - no one wants to nor has the time to spend hours on a phone trying to submit a claim to a gap cover insurer. Most insurers will have a different way or form of being able to claim so chat to your intermediary on the process that you need to follow in order to get your claim processed.
Is there one process to follow?
In order for your medical aid to cover your in-hospital procedures they need to give you authorisation. You need to then check with your gap insurer regarding covering the shortfall on what your medical aid will pay to the doctors / hospital should your medical aid not cover the full amount. You need to make sure that you have all the necessary paperwork and submit this to your gap insurer. They will make sure that the correct payments are made so you don’t really have to deal with the transfers yourself.
If you are unsure of the process, make sure that you get all the information from your intermediary - ask them to explain the step by step process as each insurer may vary. Some require an email or make use of their own APPs or deal directly with your medical aid.
For example, with the TRA Gap cover process, there are two types, a manual or an automatic process.
Manual means that you, as a policy holder need to submit the following:
Claim 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 reason for the short payment.
The automatic process means 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, it is not necessary for the Policyholder to submit their claim to TRA. TRA will receive an electronic version of the claim and will process said claim within seven (7) working days of receipt thereof. However, co-payment and sub-limit claims still have to be submitted manually by the policyholder.
Please refer to the full TRA Gap cover booklet HERE to find out more information.
Medical Gap Cover Questions & Queries
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