CLIENT CLAIM FORM / KLIËNT EISVORM - Cape …

1 TERMS AND CONDITIONS APPLY | E&OEUNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY LIMITEDCLIENT CLAIM form / KLI NT EISVORM20171 PRINCIPAL INSURED DETAILS / HOOFVERSEKERDE BESONDERHEDE1) YOUR PROFILE / JOU PROFIEL2) YOUR CLAIM DETAILS / JOU EIS BESONDERHEDEPATIENT DETAILS / PASI NT BESONDERHEDEMEDICAL PROCEDURE DETAILS / MEDIESE PROSEDURE BESONDERHEDEP ostal Code /PoskodeMedical Scheme / Mediese SkemaMedical Scheme Option / Mediese Skema OpsieMembership Number / LidmaatskapnommerMedical Scheme / Mediese SkemaMedical Scheme Option / Mediese Skema OpsieMembership Number / LidmaatskapnommerTitle / TitelFirst Name / VoornaamSurname / VanID Number / ID NommerCellphone / SelfoonTelephone (H) / Telefoon (H)Telephone (W) / Telefoon (W)Date you first experienced symptoms / Datum wanneer jy simptome die eerste keer ondervind hetSymptoms you experienced / Simptome wat jy ondervind hetStratum Benefits Policy Number /Stratum Benefits PolisnommerStratum Benefits Product /Stratum Benefits ProdukRegistered Employer Group Scheme /Geregistreerde WerkgewergroepFirst Name / VoornaamSurname / VanRelationship / Verwantskap Title / TitelID Number / ID NommerEmail Address / E-pos AdresHospital / HospitaalI aknowledge that the below details are not required when the Principal Insured is the Patient / Ek bevestig dat onderstaande besonderhede nie vereis word as die Hoofversekerde die Pasi nt is nieDay Clinic / DagkliniekPractitioner s Room / Praktisyn se SpreekkamerCasualty Ward / Ongevalle EenheidOther / AnderWhere your medical procedure was performed / Waar jou mediese prosedure gedoen isMedical condition that was diagnosed / Mediese toestand wat gediagnoseer isMedical procedure that was

2 Performed / Mediese prosedure wat gedoen isAdmission or Treatment Date /Opname- of BehandelingsdatumDischarge Date / Ontslaan DatumNAME AND CONTACT DETAILS OF PRACTITIONERS / NAAM EN KONTAKBESONDERHEDE VAN PRAKTISYNSG eneral Practitioner / Algemene PraktisynContact No / Kontak NrContact No / Kontak NrContact No / Kontak NrPractitioner who made diagnosis / Praktisyn wie diagnose gemaak hetTreating Practitioner / Behandelende PraktisynDiagnosis Date / Diagnose DatumCompletion of all fields is compulsory in order for your CLIENT CLAIM form to be processed. / Voltooing van alle velde is verpligtend vir die verwerking van jou Kli nt claimable event requires a separate CLIENT CLAIM form to be completed. / Vir elke eisbare voorval moet n aparte Kli nt EISVORM voltooi Address / Fisiese AdresPostal Address / PosadresTERMS AND CONDITIONS APPLY | E&OEUNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY LIMITEDREASON YOU ARE CLAIMING / REDE WAAROM JY EISSELECT THE BENEFIT YOU ARE CLAIMING FROM / KIES DIE VOORDEEL WAARVAN JY EISCOMPULSORY DOCUMENTS TO ATTACH / VERPLIGTE DOKUMENTE OM AAN TE HEGYour service provider charged a rate considerably more than what your medical scheme paid from your hospital benefit / Jou diensverskaffer het n tarief gehef wat aansienlik meer is as wat jou mediese skema vanuit jou hospitaalvoordeel betaal hetA detailed hospital account in the event of a hospital admission / n Volledige hospitaalrekening in die geval van n hospitaalopname+All service providers accounts / Alle diensverskaffer rekeninge +Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount

3 Paid by your scheme / Jou mediese skema eisestaat wat die bedrag ge is deur jou diensverskaffer en bedrag betaal deur jou skema aanduiYour medical scheme applied a rand amount limit to your internal prosthesis, non-PMB day procedure (applicable to G-Force only), MRI or CT scan and you are liable to pay the difference / Jou mediese skema het n randwaarde limiet toegepas op jou interne prostese, nie-VMV dagprosedure (alleenlik van toepassing op G-Force), MRI- of CT-skandering en jy is aanspreeklik vir die verskilYour medical scheme applied an overall rand amount limit on your hospitalisation and you have exhausted this limit / Jou mediese skema het n oorhoofse randwaarde limiet op jou hospitalisasie toegepas en hierdie limiet is oorskryYour medical scheme applied a co-payment or deductible to your medical procedure / Jou mediese skema het n bybetaling toegepas op jou mediese prosedureA detailed hospital or radiology account / n Volledige hospitaal- of radioloog rekening +Your medical scheme claims transaction history statement reflecting the co-payment / deductible OR proof of payment if co-payment / deductible was paid upfront / Jou mediese skema eisestaat wat die bybetaling aandui OF bewys van betaling indien bybetaling vooraf betaal isYou are claiming from your Gap Policy Premium Waiver Benefit due to the death.

4 Permanent disability or forced retrenchment of the premium payer / Jy eis van jou Gapingpolis Premiekwytskeldingsvoordeel as gevolg van die sterfte, permanente ongeskiktheid of geforseerde diensaflegging van die premiebetalerDeath certificate, doctor s confirmation of permanent disability or employer s confirmation of forced retrenchment respectively / Doodsertifikaat, bevestiging van geneesheer wat permanente ongeskiktheid bevestig of werkgewer bevestiging van geforseerde diensaflegging onderskeidelik +Proof from bank confirming premium payer / Bewys van bank wat premiebetaler bevestig You are claiming from your Medical Scheme Contribution Waiver Benefit due to the death or permanent disability of the premium payer / Jy eis van jou Mediese Skema Bydrae Kwytskeldingsvoordeel as gevolg van die sterfte of permanente ongeskiktheid van die premiebetalerDeath certificate or doctor s confirmation of permanent disability respectively / Doodsertifikaat of bevestiging vanaf geneesheer van permanente ongeskiktheid onderskeidelik +Proof from bank confirming premium payer / Bewys van bank wat premiebetaler bevestigYou are claiming from your Accidental Death Benefit due to the accidental death of the principal insured.

5 Spouse or dependant / Jy eis van jou Ongeluksterftevoordeel as gevolg van die ongeluksdood van die hoofversekerde, gade of afhanklikeDeath certificate / Doodsertifikaat Your medical scheme has only paid a portion of your oncology treatment and you are liable to pay the difference / Jou mediese skema het n oorhoofse randwaarde limiet toegepas op jou onkologie voordeel en hierdie limiet is oorskryCopy of your approved oncology treatment plan / Afskrif van jou goedgekeurde onkologie behandelingsplan +All service providers accounts / Alle diensverskaffer rekeninge +Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount paid by your scheme / Jou mediese skema eisestaat wat die bedrag ge is deur jou diensverskaffer en bedrag betaal deur jou skema aanduiYour medical scheme has applied an overall rand amount limit to your oncology benefit and you have exhausted this limit / Jou mediese skema het n oorhoofse randwaarde limiet toegepas op jou onkologie voordeel en hierdie limiet is oorskry You

6 Have been diagnosed with cancer for the first time since your cover started / Jy is vir die eerste keer met kanker gediagnoseer nadat jou dekking begin hetHealthcare provider s confirmation of first time cancer diagnosis / Bevestiging van mediese praktisyn wanneer kanker die eerste keer gediagnoseer is +Copy of your medical scheme approved oncology treatment plan / Afskrif van jou mediese skema se goedgekeurde onkologie behandelingsplanYou are claiming for a casualty event where immediate treatment was required due to physical injury / Jy eis vir n ongevalle voorval waar onmiddellike behandeling nodig was weens n fisiese beseringA detailed casualty report and casualty account / n Volledige ongevalle verslag en ongevalle rekening +Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount paid by your scheme / Jou mediese skema eisestaat wat die bedrag ge is deur jou diensverskaffer en bedrag betaal deur jou skema aanduiYou are claiming for the consultation fee charged by your registered counsellor, clinical psychologist or psychiatrist due to a traumatic event that occurred / Jy eis vir die konsultasiefooi gehef deur jou geregistreerde berader, kliniese sielkundige of psigiater vir n traumatiese gebeurtenis wat plaasgevind hetCounsellor s report and account / Berader se verslag en rekening +Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount paid by your scheme / Jou mediese skema eisestaat wat die bedrag ge is deur jou diensverskaffer en bedrag betaal deur jou skema aanduiYou are claiming for a medical procedure which your medical scheme has listed as a specific exclusion / Jy eis vir n mediese prosedure wat jou mediese skema gelys het as n spesifieke uitsluiting Quotations from all service providers such as the hospital.

7 Doctors and specialists / Kwotasies van alle diensverskaffers soos die hospitaal, dokters en spesialiste2 BENEFIT CATEGORIES & SUPPORTING DOCUMENTS / VOORDEEL KATEGORIE & ONDERSTEUNENDE DOKUMENTEN exus statements are not accepted as medical scheme transaction history statements. Refer to Your Policy Particulars or contact your broker or Stratum Benefits directly for more information regarding your underwriting and exclusions which may apply to your policy benefits. / Nexus-state is nie aanvaarbare mediese skema eisestate nie. Verwys na Jou Polis Besonderhede of kontak jou makelaar of Stratum Benefits direk vir meer inligting oor jou onderskrywing en uitsluitings wat van toepassing mag wees op jou BENEFIT / GAPING VOORDEELBase, Co-Evolution, Elite, Corporate Elite, Senior & G-ForceSUB-LIMIT BENEFIT /SUB-LIMIET VOORDEELE lite, Corporate Elite, Senior & G-ForceCO-PAYMENT BENEFIT /BYBETALING VOORDEELCo-Evolution, Elite, Corporate Elite, Senior & G-ForceGAP POLICY PREMIUM WAIVER /GAPINGPOLIS PREMIEKWYTSKELDINGE lite, Corporate Elite & G-ForceCASUALTY BENEFIT /ONGEVALLE VOORDEELBase, Co-Evolution, Elite, Corporate Elite, Senior & G-ForceCANCER DIAGNOSIS BENEFIT /KANKER DIAGNOSE VOORDEELBase, Co-Evolution, Elite, Corporate Elite & G-ForceONCOLOGY BENEFIT /ONKOLOGIE VOORDEELE lite, Corporate Elite, Senior & G-ForceONCOLOGY OPTIMISER BENEFIT /ONKOLOGIE OPTIMISER VOORDEELE lite.

8 Corporate Elite & G-ForceMEDICAL SCHEME CONTRIBUTION WAIVER / MEDIESE SKEMA BYDRAE KWYTSKELDINGE lite, Corporate Elite & G-ForceTRAUMA COUNSELLING BENEFIT / TRAUMA BERADING VOORDEELBase, Co-Evolution, Elite, Corporate Elite, Senior & G-ForceACCESS OPTIMISER BENEFIT / ACCESS OPTIMISER VOORDEELA ccess Optimiser & Corporate AccessACCIDENTAL DEATH BENEFIT /ONGELUKSTERFTEVOORDEELE lite, Corporate Elite & G-ForceHOSPITAL OPTIMISER BENEFIT / HOSPITAL OPTIMISER VOORDEELH ospital OptimiserI have attached a copy of my latest medical scheme membership certificate or membership card / Ek het n afskrif van my nuutste mediese skema lidmaatskapsertifikaat of lidmaatskapkaart aangehegI have attached the below compulsory documents relevant to my claimable benefit (Any outstanding documents will result in you having to resubmit your entire CLAIM ) / Ek het die verpligte dokumente aangeheg wat betrekking het op my eisbare voordeel (Uitstaande dokumente sal vereis dat n heel nuwe eis ingedien moet word)2) YOUR CLAIM DETAILS CONTINUED / JOU EIS BESONDERHEDE VERVOLGTERMS AND CONDITIONS APPLY | E&OEUNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY LIMITEDP lease enquire if you have not received feedback within 7 days from submitting your CLIENT CLAIM form .

9 / Doen asseblief navraag as jy nie binne 7 dae vanaf die indiening van jou Kli nt EISVORM terugvoering ontvang het ) YOUR CLAIM REIMBURSEMENT PROFILE / JOU EIS VERGOEDINGSPROFIELS tratum Benefits (Pty) Ltd reserves the right to negotiate a discounted rate with the relevant service providers on your behalf to ensure you maintain a favourable risk profile. If granted, payment will be made directly into the respective service provider s bank account thus rendering section 3 of the CLIENT CLAIM form null and void. Banking details provided as part of your CLAIM Reimbursement Profile will be the only bank account used for CLAIM reimbursements. Stratum Benefits (Pty) Ltd accepts no responsibility and cannot be held liable for any incorrect banking details provided for CLAIM reimbursements. / Stratum Benefits (Edms) Bpk behou die reg om namens jou afslag te beding met die betrokke diensverskaffers om te verseker dat jy n gunstige risiko-profiel behou.

10 Wanneer kortings beding word, sal betalings direk aan die diensverskaffers gemaak word wat afdeling 3 van die Kli nt EISVORM nietig maak. Die bankbesonderhede soos aangedui op jou Eis Vergoedingsprofiel is die enigste bankrekening wat vir die terugbetaling van eise gebruik sal word. Stratum Benefits (Edms) Bpk aanvaar geen verantwoordelikheid of aanspreeklikheid vir enige foutiewe bankbesonderhede met eise terugbetalings TO STRATUM BENEFITS (PTY) LTD / STUUR TERUG AAN STRATUM BENEFITS (EDMS) BPKREG NO: 2003/018155/07e 086 633 3761 AUTHORISATION & DECLARATION ACCEPTANCE / MAGTIGING & VERKLARING AANVAARDINGI hereby authorise my medical scheme and any service provider whom attended to me or any of my dependants, to furnish Stratum Benefits (Pty) Ltd or its authorised representatives information in respect of any medical condition, the medical history thereof and / or benefit information which may be required for the assessment of my CLAIM .