No, the CompliMed range of gap cover policies are short term insurance products that fall under the Accident and Health Policy of the Short Term Insurance Act No. 53 of 1998.
No, in order to apply for and enjoy the benefits of a CompliMed Gap cover policy you and your dependents are required to be covered under a medical aid.
Lombard Insurance Company Limited
Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571) who act as both the underwriting manager and administrator on all CompliMed Gap cover policies.
No, consultations and treatment are only covered by your CompliMed Gap cover policy during admission into a hospital ward.
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, except where there are co-payments applied to out-of-hospital MRI/CT scans.
The eligible child dependent is covered under the principal member’s policy up to the age of 25.
You are required to provide Turnberry the administrator, with 30 days written notice of your intention to cancel your policy.
No, in terms of the policy document any dependents other than those included in the definition of family will be required to be added to the principal insured’s policy under the Extended Family Cover section, for an additional premium.
Yes, the CompliMed range of gap cover policies are available to any members who are 65 years and older. Please be aware that an increased premium rate will apply to members joining at age 65 and older.
If you’ve been on your existing Gap Cover policy for 12 months or longer with no break in membership then a concession in the waiting periods will apply. In this case CompliMed will waive any waiting periods for those benefits that are the same on the policy being replaced.
NB: It remains your responsibility to cancel your existing policy with the current provider. Please ensure that the date of termination coincides with the commencement date of your new CompliMed policy.
The following waiting periods will apply from the date of commencement for all first time policy holders:
- i) A 3-month general waiting period applies to all benefits, with the exception of benefits providing cover up to 600% should the commencement of the policy be in line with the commencement date of the medical scheme.
- ii) A 10-month waiting period on pregnancy/childbirth
iii) A 12-month waiting period on: hysterectomy (except where malignancy can be proven), hysteroscopies and endometrial ablations; joint replacements and spinal investigations, treatment or surgery (except in the event of an accident); tonsillectomy, myringotomy, grommets, adenoids, wisdom teeth and treatment or surgery for a hernia (except as a result of emergency surgery), treatment and/or surgery for cataracts, gastroscopies, colonoscopies and pre-diagnosed cancer.
Yes, depending on the number of participating employees of the employer group, waiting periods will be waived and premium rate concessions may apply.
CompliMed’s premiums are priced per family per month. A Family is defined as the principal insured person, the eligible spouse, and eligible dependent children, who have not yet attained the age of 26 years, unless mentally or physically disabled and unable to earn any form of income. Any dependents falling under this deﬁnition are included at no additional cost.
Definition of a “family”: means the principal insured person, eligible spouse, and eligible dependent children, who have not attained the age of 26 years unless mentally or physically disabled and unable to earn any form of income. Any dependents falling under this definition are included at no additional cost.
If you have an extended family member registered on your medical aid and they do not qualify in terms of the above deﬁnition of a family, you may add them onto your policy for an additional premium per month.
No, as 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.
No. A claim may only be submitted after the procedure has been performed.
No. Legislation does not permit us to pay Medical Service Providers. Further, it is advisable for you not to tell your Medical Service Provider that you have a Gap Cover policy. We have incidences where providers have charged higher rates than they would otherwise have, which will have a detrimental effect on future premium rates. There are some providers that ask the question on their forms, again you are not required to disclose this information. A Gap Cover contract is between you, the client, and the insurer. No other person or institution has a right to know whether you have a contract or not.
You have 6 months from date of treatment in which to provide written notice to the Administrator, of an impending claim. Thereafter, all claim documentation must be provided to the Administrator within 12 months from date of admission, in order to avoid your claim prescribing.
When the payment will reflect in your account generally depends on with whom you bank. The time varies from 1 to 3 working days. In addition, Turnberry the administrator, will send you a claim statement, which will provide details of your claim and the amount that will be paid into your account.
Upon receipt of all the required documentation your claim will be finalised within 10 working days.
Online – www.complimed.co.za Click on the “Claim” tab and follow the prompts. Only holders of a CompliMed Enhance Plan, Extend Plan, Protect Plan and Legacy Series policy may submit their claim using the online facility.
Submit the following documentation as attachments:
- i) Copy of hospital account
- ii) Copy of all specialist accounts that relate to your in-hospital procedure
iii) Copy of medical scheme claim statement that clearly reflects all hospital and specialist accounts that relate to your in-hospital procedure.
- iv) Copy of receipts for a co-payment that may relate to your in-hospital procedure.
Waiting Periods & Exclusions
No, only in-hospital dentistry will be covered, subject to certain limitations as contained in your Gap Cover policy document. Any/all other dental work will be for your own account.
No, there is a 12-month waiting period that applies to all spinal investigations, treatment and surgery (unless as a result of an accident).
Yes, there is a 10-month waiting period that applies to pregnancy/childbirth.
No, there will be a 3-month general waiting period applied from day one of your cover for all benefits unless your gap policy date of commencement coincides with that of your medical aid plan. In this case only the benefits that provide cover of up to 600% will apply.
Yes, there is a 10-month pregnancy/childbirth waiting period that applies to your policy from date of commencement.
No, there is a 12-month waiting period that will apply to any procedures relating to grommets.
No, depression is one of the listed exceptions/exclusions that apply to your policy.
Yes, there are currently 23 exclusions in all and they are included in the Policy document. Please ensure that you read your policy document and understand the exceptions that apply to your cover.
Signed debit order authorisation form must be completed and returned to us. We will also accept a written instruction from the client giving us their new banking details.
A debit order authorisation form would need to be completed. The available debit order dates are the 1st, 7th, 15th and 25th. Should the collection date selected fall on a weekend or public holiday, a debit will be processed against your account on the first working day following the weekend or public holiday.
No, either spouse irrespective of who is reflected as the principal member on the medical aid, may be the owner on the policy. Please be aware however, that your policy will be premium rated according to the age of the oldest insured.
No. The policy terms and conditions require that premiums are paid by the due date. Turnberry will likely reject your application for reinstatement and then you will need to apply for a new policy, which will be subject to all the contractual waiting periods. If Turnberry do decide to accept your application for reinstatement it will be on condition that no benefits will be paid for any hospitalisation during the period of non-payment and any other terms and conditions Turnberry may decide to impose.
A reinstatement application form must be completed and the request for reinstatement will be underwritten. Once our underwriters have agreed to the reinstatement the policy owner will be notified and proof of payment of the arrear premiums will be required. Cover will only recommence on written acceptance and the payment of the arrear premiums.
If the policy has been in a state of lapse or cancelled for more than three months a new application form will generally be requested.
Yes, the principal insured person would be required to complete an upgrade form. Existing benefits will not be affected and will not have any new waiting periods applied. Any new benefits however, will be subject to waiting periods.
The baby will be covered from date of birth under the Gap Cover policy. To initiate the cover for the baby the principal insured person needs to complete a dependent addition form. Please note, notification of any material change to the policy contract must be submitted to us within 30 days, which would include the addition of a newborn baby. Notifications after this period may result in the baby being subject to waiting periods.
If an older child or adult dependent is added, the addition of the new member will be subject to waiting periods.
Once the baby or new dependent is added, an amended Policy Document will be issued as confirmation of the change.
The standard policy offers travel cover of R5 000 000 per insured for emergency medical expenses and does not cover pre–existing medical conditions. Should you require travel cover for pre-existing medical conditions we do offer top-up cover for an additional rate.
The MSO contact number is available on all Travel Insurance policies. You need to contact them in the event of any emergency (other than a general GP visit). They will take care of all necessary arrangements to ensure you receive the best treatment possible.
For short business trips the free travel cover is the ideal product to have when travelling. It is however important to note that the aim of the product is to provide free leisure travel insurance. The terms and conditions of the policy excludes manual labour as well as things such as off-shore drilling, being part of an airline crew and specialised sports events on a professional level. Please refer to the TIC policy terms and conditions appendix for more information.
The maximum length of your free International Travel cover is 90 days. You may purchase an additional leisure travel insurance policy from TIC in order to extend your cover until you return to South Africa. Should you require cover for more than 90 days, please contact the administrator, Lizelle at 0860 000 509, in order to obtain a quote.
You will have cover for each trip outside of South Africa provided that you have completed the application form and have been issued a travel insurance policy for the particular trip.
The turnaround time for Travel Certificates to be issued is 2 working days.