People sometimes have the perception that insurance claims are declined for ‘no reason’. However, an insurance policy is a contract. The insurer agrees to cover you according to how much risk they think they take on in doing so and set your premium accordingly. When the provisions aren’t met, the contract has effectively been broken and the insurer is exposed to more risk than ‘what your premium covers’ and ‘what was agreed to’. Beware: In the fine print there might be conditions that could disqualify your claim if not met. The insurance companies are completely within their rights not to cover you – because the contract is not valid anymore. The best course of action is to take care to understand the wording of your policy and to take the stipulations seriously. Story based on actual events, names have been changed to protect identity Rob had his car stolen at a shopping centre. He then contacted us and we registered the claim. The Insurance provider came back and requested the Car tracker logbook. Rob then informed us that his car tracker was cancelled as his policy lapsed due to non-payment. The insurance Company then requested details regarding the cancellation dates, proof of cancellation from tracking company, statements showing non-payment. Ultimately Rob could not provide any of these and later it was found that the tracker policy was under his brother’s name, this then caused the assessor to question “insurable interest” regarding the car. Upon further investigation there were other discrepancies found in the statement and the CCTV footage of the centre where the car was parked was requested for viewing. Ultimately the claim was rejected due to Condition of the policy not being met which is “Tracker is required to be active and working in order to have cover.” There are common pitfalls we see time and time again that result in insurance claims being repudiated, or only partially paid out because the ‘contract’ has been broken. Below are five key examples to look out for: 1.The regular driver and owner of a vehicle differ on a policy An example of where this happens, is if a parent is the policyholder of a vehicle that was purchased for their student child who is the regular driver. The parents have an insurable interest in the vehicle as there is a potential for financial loss if anything happens to it. In addition, if the child is not listed as the regular driver, the claim will likely be rejected and it may have an impact on the parents’ insurance risk profile. What can clients do to avoid this? Update your adviser on the full details of any new vehicle added to a policy, so that appropriate cover can be put in place. Do not assume that simply adding a vehicle to a policy will mean that it is covered. 2. Vehicle extras weren’t specified A case in point was when a client put in a claim for a bulbar that was stolen from his bakkie. No extras were noted in his policy and the sum insured was only sufficient to cover the bakkie itself. The claim was therefore rejected. What can clients do to avoid this? Ensure that all non-factory fitted accessories such as bull bars, sound systems and canopies are specified as additional extras, in addition to the sum insured value of your vehicle. Also keep in mind that you might need cover for mag rims on your tyres, so keep their replacement value in mind – anything you have changed or upgraded compared to the standard vehicle must be noted. 3. Security specifications weren’t adhered to All too common, this is an issue when claiming for a burglary/ theft. If your security features weren’t enabled at the time of the burglary, the claim will likely get rejected. If you tell your insurance company / broker that you have a tracker at the time of taking out the insurance policy it is your responsibility as the client to ensure that this tracking devise must have a valid contract and always be in a working order to prevent problems at claims stage, the client is responsible to ensure that the devise is active and working. If the tracker is no longer active the insurance company needs to be notified ASAP. On high value vehicle this may be a requirement in order to retain insurance cover. What can clients do to avoid this? Make sure you ask about any elements of your cover that are your responsibility. If you are covered for having a locked security gate, vehicle tracking devise, an active electric fence or burglar bars on your windows, these features need to be in place and in good working order at all times. This will keep both your property and you safe. 4. You moved but didn’t say anything to your insurer If you move and don’t notify your insurer of your new address, any claims at the new premises will be rejected. This might seem like an obvious change to make to your policy, but we do experience clients forgetting. What can clients do to avoid this? Insurers usually require that you give written notice of your new permanent, physical address before you move. This is because your new address means your risk has changed and your premium may also change. If you would like us to review your current policy contact Edmond in our Short-term department email; service@daberistic.com tel(011)658-1333 ext 105. Source: Apollotechnical.com, Business Report
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People sometimes have the perception that insurance quotes are declined for ‘no reason’. However, an insurance policy is a contract. The insurer agrees to cover you according to how much risk they think they take on in doing so and set your premium accordingly. When the provisions aren’t met, the contract has effectively been broken and the insurer is exposed to more risk than ‘what your premium covers’ and ‘what was agreed to’. Beware: In the fine print there might be conditions that could disqualify your claim if not met. The insurance companies are completely within their rights not to cover you – because the contract is not valid anymore. The best course of action is to take care to understand the wording of your policy and to take the stipulations seriously. Story based on actual events, names have been changed to protect identity Rob had his car stolen at a shopping centre. He then contacted us and we registered the claim. The Insurance provider came back and requested the Car tracker logbook. Rob then informed us that his car tracker was cancelled as his policy lapsed due to non-payment. The insurance Company then requested details regarding the cancellation dates, proof of cancellation from tracking company, statements showing non-payment. Ultimately Rob could not provide any of these and later it was found that the tracker policy was under his brother’s name, this then caused the assessor to question “insurable interest” regarding the car. Upon further investigation there were other discrepancies found in the statement and the CCTV footage of the centre where the car was parked was requested for viewing. Ultimately the claim was rejected due to Condition of the policy not being met which is “Tracker is required to be active and working in order to have cover.” There are common pitfalls we see time and time again that result in insurance claims being repudiated, or only partially paid out because the ‘contract’ has been broken. Below are five key examples to look out for: 1.The regular driver and owner of a vehicle differ on a policy An example of where this happens, is if a parent is the policyholder of a vehicle that was purchased for their student child who is the regular driver. The parents have an insurable interest in the vehicle as there is a potential for financial loss if anything happens to it. In addition, if the child is not listed as the regular driver, the claim will likely be rejected and it may have an impact on the parents’ insurance risk profile. What can clients do to avoid this? Update your adviser on the full details of any new vehicle added to a policy, so that appropriate cover can be put in place. Do not assume that simply adding a vehicle to a policy will mean that it is covered. 2. Vehicle extras weren’t specified A case in point was when a client put in a claim for a bulbar that was stolen from his bakkie. No extras were noted in his policy and the sum insured was only sufficient to cover the bakkie itself. The claim was therefore rejected. What can clients do to avoid this? Ensure that all non-factory fitted accessories such as bull bars, sound systems and canopies are specified as additional extras, in addition to the sum insured value of your vehicle. Also keep in mind that you might need cover for mag rims on your tyres, so keep their replacement value in mind – anything you have changed or upgraded compared to the standard vehicle must be noted. 3. Security specifications weren’t adhered to All too common, this is an issue when claiming for a burglary/ theft. If your security features weren’t enabled at the time of the burglary, the claim will likely get rejected. If you tell your insurance company / broker that you have a tracker at the time of taking out the insurance policy it is your responsibility as the client to ensure that this tracking devise must have a valid contract and always be in a working order to prevent problems at claims stage, the client is responsible to ensure that the devise is active and working. If the tracker is no longer active the insurance company needs to be notified ASAP. On high value vehicle this may be a requirement in order to retain insurance cover. What can clients do to avoid this? Make sure you ask about any elements of your cover that are your responsibility. If you are covered for having a locked security gate, vehicle tracking devise, an active electric fence or burglar bars on your windows, these features need to be in place and in good working order at all times. This will keep both your property and you safe. 4. You moved but didn’t say anything to your insurer If you move and don’t notify your insurer of your new address, any claims at the new premises will be rejected. This might seem like an obvious change to make to your policy, but we do experience clients forgetting. What can clients do to avoid this? Insurers usually require that you give written notice of your new permanent, physical address before you move. This is because your new address means your risk has changed and your premium may also change. If you would like us to review your current policy contact Marizka in our Short-term department email; service@daberistic.com tel(011)658-1333 ext 108. Source: Apollotechnical.com, Business ReportSpring season is finally here and that means the year is coming to an end. We can see a trend that more and more countries are opening up for tourists. In the time of such a pandemic it also reminds us how important it is to have medical cover abroad. Most medical schemes include international travel medical benefits, but each company's benefits are different. With some medical schemes you need to ensure that you need to activate your International Travel Benefit before you travel. With Discovery Health you do not need are to phone ahead to “activate” this benefit, all you need is your departure and re-entry stamps in your passport as proof! Depending on your chosen medical aid option, your cover limit will either be R5 Million or $1 Million and that will alleviate the burden off your shoulders knowing that you will be able to receive the best medical attention whilst on your travel adventures. Should you wish to find out more about International Travel Benefit topics such as:
If you will be travelling and may require a vaccine certificate, you may contact EVDS on 0800 029 999 to request a vaccine certificate for travel. This is a special request that they do and they will provide the member with an email address to send their information. They will need the below information:
If you have any other queries, please contact Namhla, Tammy or Jo in our Health department, email service@daberistic.com, Tel 011-6581333, Option 2 for Medical Aid. When to take a test and when will it get covered? You’re covered for 2 COVID-19 Polymerase Chain Reaction (PCR) screening tests every calendar year (1 January to 31 December), regardless of the outcome of the test. Medical Aid will pay for COVID-19 diagnostic tests, provided that the member who took the test:
Will you have to pay upfront and submit a claim for it to be paid from this benefit? This depends on the payment arrangements your medical aid have with your healthcare provider. If your healthcare provider submits a claim on your behalf, your medical aid will reimburse them directly subject to meeting the clinical entry criteria of the benefit. If your doctor requires you to pay upfront, you can submit your claim to your medical aid. What does it mean if I test positive for the PCR test? A positive PCR result confirms that you are infected and that you can spread it to others. You would need to contact your doctor to discuss the implications of this finding and the next steps to take, whether this be to self-isolate at home and/or on your planned hospital admission. If I test Positive, how do I self-isolate and for how long do I self-isolate? If you are infected and are asymptomatic i.e. you show no symptoms, you must stay at home and self-isolate for 10 days from the date of your positive test. In case of severe respiratory illness or severe shortness of breath you need to immediately consult with your doctor or go to the nearest hospital emergency unit. In case of severe disease, you will probably be hospitalised, and you would need to continue to self-isolate for 10 days after clinical stability is achieved. If I test positive for Antibody test, will I have immunity to COVID-19 infections in the future? As COVID-19 is a new virus, we cannot tell for sure how long antibodies will last or how well they can protect against future infections. Even though it is believed that a person will have some level of immunity after infection, which is the scientific principle that the development of a vaccine is based on. However, all individuals should still adhere to recommendations by the department of health on social distancing, hygiene, and personal protection, regardless of their antibody test result. How am I covered for COVID-19? This benefit, available on all plans, is covered by the scheme for cases of outbreak diseases and out of hospital healthcare services related to COVID-19. These healthcare services are covered up to maximum of 100% of your chosen medical scheme’s rate in accordance with Prescribed minimum benefits where applicable. Am I covered if I am in a waiting period? The scheme resolved to change its’ approach to underwriting for the duration of the outbreak, specifically with regards to cover for COVID-19. Members that are diagnosed with COVID-19 after joining will have access to the benefit, even if they are subject to a waiting period at the time of being diagnosed with COVID-19. Members that are diagnosed with COVID-19 before joining the scheme will not have access to the benefit and will be subject to waiting period to protect the scheme and its members against anti-selection. Emergency care – When should I call 911 or go to the emergency department? Call ER24 on 084124 if you are experiencing potentially life-threatening symptoms. These are some of the symptoms for which you should immediately call ER24;
What if I’m afraid to go to the emergency department? We understand those fears, but emergency department staff members wear personal protective equipment, and all places are fully cleaned and disinfected. Please note, that waiting too long to seek care for some health care emergencies is a bigger risk than the chance of contracting COVID-19. How do I know I won’t get COVID-19 in the emergency department? Depending on the urgency of the patient’s medical needs, everyone entering the emergency department is immediately screened for symptoms of COVID-19. How do I know I won’t contract COVID-19 if I need to stay in the hospital for treatment?
All labour and delivery patients – How are women protected whom come in for labour and delivery? In order to prevent the spread of COVID-19 and protect the health of all patients and staff members, testing for COVID-19 and taking precautions for each woman who is admitted to labour and delivery for delivery. The care team will follow special infection prevention procedures and wear proper personal protective equipment. Depending on the woman’s COVID-19 test results, she may be cared for in a special room and according to COVID-19 guidance for deliveries. What to expect when you go to the hospital During the COVID-19 pandemic, we have extra measures in place to prevent the spread.
Registration for COVID-19 Vaccine Acting health minister Mmamoloko Kubayi-Ngubane has announced a major boost to South Africa’s Covid-19 vaccination plans, with vaccines now being made available to more age groups and on weekends. Kubayi-Ngubane said that the government had also agreed to open vaccine registrations to people in the 35 – 49 age group.
All staff will be vaccinated, even if you’re not part of Discovery health, if they are part of company staff list, then they are eligible to receive vaccination. Should you be interested, please contact us and we will assist to communicate with Discovery to action Discovery Vaccination programme for employers.
Vaccination during riots and civil unrest period Please note that some of the vaccination sites that are affected are temporarily closed due to looting, riots and civil unrest. The vaccination rollout will be delayed but still encourage all clients to please use their digital form to register and make appointments. Those that missed their appointment due to recent looting will be rescheduled. If you have any other queries please contact our Health department, email service@daberistic.com, Tel 011-6581333, Option 2 for Medical Aid. I have used up my Medical Savings Account, can I still see a doctor? I am a loyal customer of Discovery and have been a member of Discovery Health since I entered the workplace in 1996. During my start-up years from 2006 to 2009, I moved to my wife's company medical aid Sasolmed, then later changed to Medicover. In 2009, I returned to Discovery Health. My medical aid option has been Classic Delta Saver for the last few years. I think this plan is value for money, suitable for our family of five. However, towards the end of the year, I often run out of Medical Savings Account, then I have to pay out of my own pocket to see a doctor or to buy medicine. This plan provides Day-to-Day Extender Benefits: even when the savings account is used up, you can still visit a designated GP and be covered by Discovery. Discovery Health covers up to 6 network GP visits, which is helpful. The protocol to access this extender benefit has changed since the end of last year, however. Although I am a healthcare broker, I forgot to keep up with the change. I still wanted to use the same procedure as I have used in the past. I then ran into a wall and the Discovery Health refused to pay. What is going on here? There were like R30 left in my MSA. In order to use the extender benefits, I went to Dis-chem pharmacy to buy over-the-counter medicine. The intention was to reduce the savings account to zero. I asked the pharmacist to deduct from my savings account first, and I would pay the balance in cash. I also asked the pharmacist to confirm that there was no money in my savings account. After that, I made an appointment for my son with a designated family doctor, to assess his spinal injury. After the consultation, the front desk staff said that the claim had been submitted to Discovery Health, so I didn't have to pay for it. I thought that this extender benefit was really good, only to receive a claim statement from Discovery a few days later that they did not pay. I thought there was some misunderstanding. Upon further investigation, it turned out that I didn't apply the knowledge acquired. At the end of last year, Discovery announced a new process to use extender benefits. The first is to go to a network pharmacy such as Dis-chem to see a nurse. Or download the Dr Connect app on your mobile phone to consult with a doctor online. The infographic below illustrates: Below are the steps of how DrConnect works 1. Download DrConnect on the smart phone 2. Open the APP and log in 3. Log in with your Discovery Username and Password 4. You will see 4 categories: Assess your symptoms, Talk to a doctor, Ask doctors your questions, Enrol in a care guide. 5. If the GP you have visited before is also a DrConnect network doctor, he/she will appear here. Click the doctor for more options. 6. You can choose to book an appointment, send them a message about your queries, or connect for a video consultation (when they are online). 7. Or, on the main page (home), choose to ask a question. 8. Type in the question you would like to ask. 9. Answer a quick health survey or click Skip to skip it. 10. There may be other people have asked a similar question, which already has an answer to, see if you can find your answer here, if not, click to send your question.
1.Claiming from Medical Aid Daily Claims The day to day claims, like your Gp, Specialist, buying medication will be covered from your MSA Benefit, however if you are using a hospital plan, day to day is not submitted. Hospital claims. This is any claim that has been authorized for hospital stay, this can be a day or more than, so this will be paid from the hospital benefit Documents required to submit claim Valid invoice, not older than 3 months which must include, - Dr Details, Practice number, service date, ICD10 Code and Procedure code - Details of the patient i.e Name, surname and date of birth, Medical aid number Where to submit Medical Aid claim
2.Claiming From Sirago Any claims that needs to be submitted to Sirago has to submitted to your medical aid before claiming from the Gap Cover. Gap cover will only pay if it’s a valid claim which is based on one of the following:
Documents required to submit claim -Complete claim form -Invoices -Hospital statement -Medical aid statement, reflecting all the invoice or providers that has shortfall Where to submit
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AuthorKevin Yeh Archives
January 2025
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