Who can claim?

You and your healthcare providers (general practitioner, specialist, pharmacy or hospital) can submit claims directly to the Scheme.

What information must be included on your claims?

  • Your membership number
  • The Scheme name
  • Your benefit option (for example Optimum, Custom, etc.)
  • Your surname and initials
  • The patient's name and beneficiary code as it appears on your membership card
  • The name and practice number of the service provider
  • The date of service
  • The nature and cost of treatment
  • The pre-authorisation number, if applicable
  • The tariff code
  • The ICD-10 code
  • If you paid for the service, attach proof of payment and highlight it clearly. Proof of payment can be a receipt from the healthcare provider, an electronic fund transfer (EFT) slip or a bank deposit slip.

Reasons why claims are rejected

  • Incorrect member or dependant information
  • Dependants are not registered or their details do not appear on the claim
  • No pre-authorisation number was obtained for treatment that required pre-authorisation
  • Benefits not available
  • Claims will not be paid if the benefit category you are claiming from has been depleted

Ensure that all the required  information is reflected on the claim (as indicated above)

Where do I send my claim?

Fax: 031 5800 429
Post: PO Box 2338, Durban, 4000

Claims received after the claiming period has expired

Claims must reach the Scheme within 4 months (i.e. 120 days) of the treatment date. The Scheme will not pay claims that are older than 4 months. You will be responsible for paying the claim if you have submitted it to us after 4 months.

Claims received after you have resigned from the Scheme

When you resign from your employer, your Scheme membership of the Scheme ends and you will not be allowed to access healthcare services. If you or your healthcare providers claim for healthcare services rendered after the date that you resigned from the Scheme, the claim will not be paid.

Scheme exclusions

You must ensure that the procedure, treatment or product you plan to claim for qualify, for benefits before obtaining it, as the Scheme will not pay for any services that are excluded in terms of the Scheme Rules. You will be responsible for paying those costs directly to the healthcare providers. Scheme exclusions are listed on page 46. Alternatively, visit for a complete list of exclusions.

Please submit your claims directly to