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How Does Co-Payment Cover Work?

A co-payment or deductible is an upfront amount that needs to be paid to the hospital/day clinic/radiologist before undergoing certain procedures, as specified by your Medical Scheme.

When you experience a co-payment for a procedure or scan (as specified by your Medical Scheme) you would need to pay for the co-payment up-front and then claim the amount back from your CompliMed® policy (provided that the plan you selected offers a co-payment benefit.) If your Medical Scheme pays for co-payments from your day-to-day benefits you may still claim the amount back from your CompliMed® policy.

Covered by CompliMed^® Plans:

• Legacy Series

How Does Medical Expense Shortfall Cover Work?

A Medical Expense Shortfall is the difference between what medical service providers (e.g. Doctors, basic and specialised Radiology, Pathology, Specialists) charge and what Medical Schemes pay for the treatment performed in hospitals and day clinics, provided that it is paid from the Hospital Benefit of your Medical Scheme. Medical Expense Shortfall Cover will boost your Medical Aid rate, helping you with this shortfall!

Covered by CompliMed^® Plans:

• Legacy Series: 600%

Below is an example of a claim for a Hip replacement:

Medical Service Provider	Amount Charged by Medical Service Provider	Amount Paid by Medical Scheme	Amount Paid by CompliMed®
Surgeon	R17,053	R6,021	R11,032
Anaesthetist	R8,256	R2,402	R5,854
		Total Paid by CompliMed®	R16,886

Declaration by the Principal Insured Person

I understand that this online application and declaration shall form the basis of the contract between me and Lombard Insurance Company Limited (Insurer). I hereby warrant that the answers and statements provided by me in this online application are true and correct in every particular and that I have withheld no information whatsoever, which is material to or is likely to affect the assessment of the risk under the proposed insurance. I undertake to advise Turnberry (Administrator) in writing if a change takes place in the health of the insured person/s between the date of submitting this online application and the date of acceptance of the risk or the date of commencement of the policy, whichever occurs last. I understand that any inaccurate and untrue statements or failure to notify Turnberry of a change in health prior to the acceptance and/or commencement of the policy may render my policy null and void and all premiums paid will be forfeited back to the Insurer. I acknowledge that no representation made to me by any agent or employee of the Insurer shall in any way bind the Insurer unless it is thereafter confirmed in writing by the Insurer. I hereby irrevocably authorize a) the Insurer to obtain from any person any information the Insurer needs to which this application relates; b) the person concerned to give the Insurer the information it requests under the authorization in (a); the Insurer to share with other insurers and with ASISA any information to assess risks or claims. Any information may under this authorisation be obtained or given at any time, even after death. I agree that this online application is as effective and valid as if I had completed and submitted an original application form. I confirm that all future correspondence between myself, CompliMed, Turnberry and Lombard will be via email and that I will not hold any of these parties liable for any loss or damage arising through any unauthorized access to any email correspondence in the future.

I acknowledge that should any of my personal and/or banking details change it is my responsibility to ensure that Turnberry is notified of the changes.

I acknowledge that the premium quoted is due monthly in advance on the first day of each calendar month and if not received by Turnberry by the 15th day of the following calendar month, then this policy shall be deemed to have been cancelled at midnight on the due date.

I confirm that I have exercised my own free choice when applying for Gap cover insurance with CompliMed and that no advice has been provided in this regard.

In the event that this policy is replacing an existing policy with the same or similar benefits I am satisfied that I am aware of any differences there may be in the product benefits and any new restrictions that may apply to the new policy.

The full terms and conditions and disclosures are included in the policy documentation that is sent to me after sign-up.

How Does Sub-Limit Cover Work?

When a Medical Scheme will only pay for a certain procedure, prosthetic device or scan up to a specified limit, this is a sub-limit.

Example: Joe gets admitted to hospital for a hip replacement. After the procedure, he notices that the cost of the prosthetic hip was R60 000, but his Medical Scheme only paid R50 000 towards the prosthetic hip, leaving him liable for R10 000. Luckily for Joe, he has a CompliMed® policy that offers sub-limit cover of R20 000 per admission. Therefore Joe can submit the account to CompliMed® to pay the R10 000 difference from his CompliMed® policy.

Covered by CompliMed^® Plans:

• Legacy Series

How Does Non-DSP Hospital Penalty Cover Work?

Should you choose to go to a hospital or day clinic outside of your Medical Scheme’s Hospital Network/Designated Service Providers, you would be liable for a portion of the account, as specified by your Medical Scheme.

Example: Johnny’s Medical Scheme stipulates that he needs to go to hospital X, if he chooses to go to another hospital he would need to pay the first R11 000 of the hospital account. Johnny chooses to go to hospital Y and pays the R11 000 and then claims it back from his CompliMed® Legacy Series policy.

Covered by CompliMed^® Plans:

• Legacy Series

Terms and Conditions

Full terms and conditions and Disclosures are included in the policy documents that are sent after sign-up. These should be read in full after you have taken out a CompliMed^® Gap cover policy. You will have the right to cancel the policy within 30 days of receiving the policy documentation at no cost and any premiums already paid will be refunded back to you.

CompliMed^®

CompliMed^® (Pty) Ltd registration number 2003/019934/07, is an authorized financial services provider (FSP 14381), licensed by the Financial Services Board to supply, amongst other categories, Short Term Personal Lines, of which accident and health policies (gap cover) forms part thereof. CompliMed^® has an independent compliance officer and her details are as follows:
Louise Pardy, L Pardy and Associates, lpardy@vodamail.co.za

The Insurer

The insurer is Lombard Insurance Company Limited registration number 1990/001253/06. Lombard is an authorized financial services provider (FSP 1596) providing the risk on all CompliMed^® Gap cover policies. The insurer’s compliance officer is Ms. R Platte who can be contacted on the following telephone number: 011 551 0600 or compliance@lombardins.com

The Underwriting Manager and Administrator

Turnberry Management Risk Solutions (Pty) Ltd registration number 2007/026488/07 acts as the medical gap insurance specialists for Lombard Insurance Company Limited. Turnberry is an authorized financial services provider (FSP 36571) and have appointed Mrs. S Gerald as their compliance officer who can be contacted on 011 9691649. Turnberry will also be performing all the admin functions on the CompliMed^® range of Gap cover policies which will include the issuing of policies, collecting of premiums and the assessing and paying of claims. Turnberry can be contacted on the telephone number: 0861 000 508 or email: newbusiness@turnberry.co.za

Application Process

CompliMed^® distributes their products via the website and sign-up of a gap cover policy is done by completing an online application. By signing up for a CompliMed^® policy, you agree to abide by the terms and conditions of both Turnberry the administrator and Lombard the insurer. Once your CompliMed^® online application has been submitted, the administrator Turnberry will process your application and check the personal banking details provided by you to ensure that they are correct. Once the administrator has accepted your application on behalf of the insurer a CompliMed^® policy will be issued. You may cancel this policy at any stage by providing 30 days notice in writing to the administrator. You may send an email to: admin@turnberry.co.za

The CompliMed^® Contract

Your Gap Cover policy consists of your online application, policy schedule and policy document. CompliMed^® policies are underwritten by Lombard and administered by Turnberry. This means that Turnberry are responsible for assessing and paying claims under the policy on behalf of Lombard. CompliMed^® markets and distributes their gap cover products using the website but your agreement to pay all monthly premiums are directly with Turnberry.

The cover you have under your CompliMed^® policy will be explained fully in your policy document. Be sure to read your policy document carefully, double check all the details in the document, taking special attention to read and understand all relevant waiting periods and exclusions that will apply to your cover. Should you have any questions in this regard please contact CompliMed^® on the email: admin@complimed.co.za

NB. This is not a medical scheme and cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership.

Personal Information

CompliMed^® takes the protection of your personal information very seriously. By accepting the terms and conditions, you consent to the sharing of your information knowing that this will be kept confidential.

We respect your privacy and take great care to protect the confidential information you give us: we will deal with it in a lawful manner. CompliMed^® will not share your personal information with any other third party except if it is required to do so in the ordinary course of business, or where required by law. We don’t like spam and we won’t sell your details to anyone for their marketing purposes.

CompliMed^® may collect and process certain personal information for communication and administrative purposes. Collection and processing of this information will help us give you a better service and create products tailored to meet your needs.

Financial Advice

CompliMed^® is an authorized financial services provider marketing Short Term Insurance products underwritten by Lombard and administered by Turnberry. CompliMed^® does not offer financial advice as defined by the Financial Advisory and Intermediary Services Act (FAIS) on any products sold via the website.

Premium Payment

Turnberry the administrator facilitates the collection of your CompliMed^® Gap cover premiums on behalf of Lombard the insurer. You agree that you will pay the premium on the specified date(s) and authorize Turnberry to debit your bank account information provided in your online application. Premiums will be payable monthly in advance from the start date of your policy, and your obligation to pay a monthly premium will remain as long as your policy is in effect. Turnberry may vary the premium rate under this policy at any time, by giving thirty (30) days notice written notice. All premiums related queries can be directed to the following email address: debtors@turnberry.co.za

Term

The cover on your CompliMed^® policy will start as soon as your policy commencement date is reached. Your specific commencement date is noted on your policy schedule and your policy will automatically be renewed on 1 January every year, as long as you continue to pay premiums.

Cool-off Period

If you change your mind and want to cancel this policy within the first 30 days from taking it out, we will refund you any premiums you have already paid. If you decide to cancel your policy after this date, you’ll lose any premiums already paid.

Policy Reinstatement

Should your CompliMed^® policy be cancelled for whatever reason, a request to reinstate the benefits must be made to the administrator Turnberry in writing. It may be reinstated at the absolute discretion and subject to the requirements of Turnberry.

Claims

Claims are processed and paid by the administrator Turnberry, in strict accordance to the terms and definitions of your CompliMed^® policy. Please ensure that you read and fully understand all the waiting periods and exceptions that apply to your cover.

Non-Disclosure

If you have given false information in your application your claim may not be paid.

Debit Order

Turnberry the administrator will attempt to deduct the premiums on your CompliMed^® policy in accordance with the date you selected, but should this date fall on a weekend or public holiday, they may be required to collect a premium on the first working day thereafter. The debit order reference reflected on your bank account for any premium collected will be “TMS Health.”

Replacement Policy

If this policy is replacing an existing policy please ensure that you have carefully compared the premiums, benefits and all terms and conditions of your CompliMed^® policy with the policy being replaced.

You may enter a waiting period that applies to your CompliMed^® policy that no longer applies to your existing policy.

Your existing policy may have different exclusions (events that are not covered) than those on your CompliMed^® policy.

No waiting periods will apply to any benefits on your CompliMed^® policy where such benefits are similar by definition to those being replaced (like-for-like), and where the replaced policy has been in force for at least 12 months or longer. Please be advised that proof of current cover will need to be provided when applying for a CompliMed^® policy, in order to avoid any new waiting periods being applied.