General

Does Complimed form part of my medical aid?

No, Complimed Gap cover is a short term insurance product that falls under the Accident and Health Policy of the Short Term Insurance Act No. 53 of 1998.

Can I claim for routine visits to my GP?

No, consultations and treatment are only covered by your Complimed Gap cover policy during admission into a hospital ward

Does my Complimed Gap cover policy pay for any/all shortfalls not covered by my medical aid?

No, primarily shortfalls created by specialist charges for in-hospital procedures are covered by your policy within certain limits (refer to policy document). Generally, out-of-hospital procedures, day-to-day consultations and related shortfalls are not covered.

My child dependant has reached the age of 21 and my medical scheme has changed his/her status to that of an adult. How does Complimed deal with this change?

Should your child turn 21 and still be unmarried and a full time student, then they will continue to enjoy cover under your policy until the age of 25. However, should they not be studying full time when turning 21, they will no longer be covered under your policy and will be required to apply for their own Complimed policy

How do I cancel my policy with Complimed should I no longer see the need to continue with this cover?

You are required to provide Complimed with 30 days written notice of your intention to cancel your policy.

I have an existing Complimed Hospital Self-Payment Protector policy and have been advised by my medical scheme that I will be required to make a co-payment on admission to hospital for a planned in-hospital procedure. Will my Complimed Hospital Self-Payment Protector product cover this shortfall ?

Yes, most in-hospital procedures where you are required to make a co-payment will be reimbursed to you in terms of the definitions contained in the policy document.

My specialist has charged at 450% or 4 ½ times the medical scheme's health rate for an in-hospital procedure. Will the whole shortfall be covered by my Complimed Health Rate Enhancer policy?

Yes, from 2012 onwards the cover on your Complimed Health Rate Enhancer policy will provide you with cover up to 500% or 5 times the medical scheme's health rate.

My medical scheme has asked me to make payment for an in-hospital procedure in full, as they don't provide cover on this particular procedure. Will my Hospital Self-Payment Protector policy pay this shortfall?

No, only co-payments or deductibles levied by your medical scheme are covered under this policy. Where no payment at all is made by your medical scheme for a particular procedure, there will be no benefit due under this policy.

I would like to apply for the Cancer Treatment Enhancer policy. My spouse however, was been treated for a malignant skin lesion 3 years ago. Will she still qualify for cover?

No, should you or any one of your dependants have ever suffered from or been treated for any form of cancer in the past, that dependant will not qualify for cover under this policy.

My daughter is due to undergo a cochlear implant and I am aware that my medical scheme provides limited cover in this regard. What cover will I enjoy under my Complimed Hospital Sub-Limit Extender policy?

As your medical scheme has listed this procedure as having limited cover, Complimed will provide an additional R30, 000 to assist you with this shortfall, in terms of this policy.

My parents are currently listed as adult dependants on my medical scheme. Are they covered under my Complimed Gap cover policy as well?

No, in terms of the policy document adult dependants will be required to apply for their own policy.

I have recently changed my bank account. What does Complimed require in this regard?

You are required to provide Complimed with a Change of Banking Details form as soon as possible, which you can download from our website and email to the admin office

I have been enjoying Complimed Gap cover through my employer, but have recently resigned. I would like to continue with my policy, is this possible?

Yes, you may continue to enjoy the benefits of your Complimed Gap cover policy in your individual capacity. Complete and submit a Continuation Option form within 60 days of you resigning from your employer. Kindly enquire about the terms and conditions that apply to a Continuation.

I do not have a medical aid, but have a medical insurance policy. Can I apply for a Complimed Gap cover policy in order to enhance my medical cover?

No, in order to qualify for a gap cover policy you are required to be a member of a registered medical aid scheme.

I am 75 years old and would like to apply for Complimed Gap cover. May I do so?

Yes, Complimed now offers a policy for those members between the ages of 71 and 80.

Claims

As an existing Complimed policyholder am I obliged to inform Complimed of an upcoming in-hospital procedure?

No, as Complimed Gap cover is a short term insurance policy, any claims need to be intimated after the event. You will be liable to settle any shortfalls with your service providers upfront and claim back from your policy benefits thereafter.

How long do I have to submit a claim form to Complimed after undergoing an in-hospital procedure?

Complimed must be advised in writing (Health Claim form) within 6 months of date of admission to hospital

How long will it take Complimed to have my claim paid out to me?

In the event that Complimed receives all claim documentation upfront, we will reimburse the client in terms of the policy document within 14 days.

I have recently undergone an in-hospital procedure and my attending doctor has requested that I settle his account immediately. In the event that I submit the account to Complimed will you settle the account directly?

No, in terms of current legislation governing short term health insurance policies, all claim benefit payments have to be paid to the principal member only.

Waiting periods & exclusions

I have an existing Complimed policy and I am due to have extensive dental work done in the dentist's chair, will this be covered by my Complimed Gap cover policy?

No, only in-hospital dentistry will be covered, subject to certain limitations as contained in your Complimed policy document. Any/all other dental work will be for your own account.

I have been suffering with a bad back for years and after much treatment and medication my doctor has suggested I undergo a back procedure. Can I apply for a Complimed Gap cover policy now and have the upcoming procedure covered by my policy?

No, there is a 12-month pre-existing condition exclusion applied to your policy, which will exclude any procedure performed in the first 12 months of your policy, should you have received treatment or advice from a doctor for the same or similar ailment in a 12 month period prior to applying for cover with Complimed.

My wife is currently pregnant. Can I apply for Complimed Gap cover and have the childbirth procedure covered by my policy?

No, there is a 12-month exclusion that is applied to all hospitalisation due to pregnancy and/or childbirth that applies to your policy from date of entry.

Can I claim immediately after I have been accepted onto cover?

No, there will be a 3-month general waiting period applied to all new policies for all procedures other than admissions as a result of an accident

My wife is currently 4 months pregnant. I would like to apply for Complimed Gap cover. Will there be any limitations and/or exclusions in regard to the pregnancy?

Yes, amongst other listed exclusions there is a 12-month pregnancy and childbirth waiting period applied to your policy from date of inception.

I have been on cover with Complimed for 4 months and have found out very recently that my wife is currently 7 weeks pregnant. Will the childbirth be covered under my policy?

Yes, assuming the childbirth takes place after the first 12 months of the policy, the procedure will be covered.

My child has been suffering from recurring ear infections in the 12 months prior to me applying for a Complimed Gap cover policy. Will her upcoming grommet procedure with the ENT be covered by my policy in the first year?

No, there is a 12-month pre-existing condition exclusion applied to your policy from inception. No claim will be entertained for any procedure that is related to treatment or advice received by you or your dependants in the 12 months prior to the policy inception date.

I am an existing policyholder with Complimed and my wife has recently been admitted to a hospital due to depression. Will she be covered in terms of our Complimed Gap cover policy?

No, depression is one of the listed exclusions that apply to your policy.

Besides the 3 waiting periods stated on the application form, are there any other exclusions I need to be aware of?

Yes, there are currently 18 exclusions in all and they are contained in the Master Policy document. Please ensure that you take note of them all.