The Turnberry Claim Form - Online Application

Policy Number or ID Number of Principal Person Insured*

DETAILS OF PRINCIPAL INSURED PERSON

Name*

Title First Name - As it appears on your ID Surname - As it appears on your ID

Postal Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Cell Phone Number*

Work Phone Number*

Home Phone Number*

MEDICAL AID INFORMATION

Medical Aid*

Medical Aid Option*

Medical Aid Number*

DETAILS OF PATIENT

Please note that patient details do not need to be completed if the Principal Insured is the patient*

The patient is the principal insured person
The patient is not the principal insured person

Name of the patient*

Title First Name - As it appears on your ID Last

Patient ID Number/ Date of birth*

Referring Doctor/ GP Name*

Referring Doctor/ GP Number*

TREATMENT DETAILS

Where did you receive your medical treatment*

Please specify*

Treatment date/ Date of admission*

Date of Discharge*

BENEFIT YOU WOULD LIKE TO CLAIM FOR

Select the benefit you are claiming for*

Medical Scheme Contribution Waiver and Gap Premium Waiver*

Permanent and total disability
Death

Please select the type of claim*

Permanent and total disability
Death

Are you claiming for the Principal Insured person*

Yes
No

Please upload the below documents to file your claim:

Doctors Invoices / Accounts*

Drop files here or

Max. file size: 2 MB.

Medical Aid Claims Statement*

Drop files here or

Max. file size: 2 MB.

Full Hospital account*

Drop files here or

Max. file size: 2 MB.

Hospital account/Day Clinic Account/Radiology account*

Drop files here or

Max. file size: 2 MB.

Hospital account / Day Clinic Account*

Drop files here or

Max. file size: 2 MB.

Hospital account / Day Clinic Account / Radiology Account / Doctors Account / Pathology account*

Drop files here or

Max. file size: 2 MB.

Hospital account / Day Clinic Account / Radiology Account / Doctors Account / Pathology account/ Pharmacy accounts*

Drop files here or

Max. file size: 2 MB.

Accounts for the Biological Cancer Drug (Pharmacy)*

Drop files here or

Max. file size: 2 MB.

Casualty account*

Drop files here or

Max. file size: 2 MB.

Doctors and/or Radiology accounts*

Drop files here or

Max. file size: 2 MB.

Histology report*

Drop files here or

Max. file size: 2 MB.

Report from Oncologist*

Drop files here or

Max. file size: 2 MB.

Treatment plan*

Drop files here or

Max. file size: 2 MB.

Medical report stating the disability*

Drop files here or

Max. file size: 2 MB.

Proof of the Medical Scheme Contribution Payer (bank statement or letter from Medical Scheme)*

Drop files here or

Max. file size: 2 MB.

Medical Scheme Certificate reflecting the contribution*

Drop files here or

Max. file size: 2 MB.

Death Certificate*

Drop files here or

Max. file size: 2 MB.

Executorship Letter or Letter of Authority*

Drop files here or

Max. file size: 2 MB.

Needs to be on the relevant letterhead

Estate Banking Details*

Drop files here or

Max. file size: 2 MB.

Please note it needs to be on the relevant banks letterhead

Police report*

Drop files here or

Max. file size: 2 MB.

Police report*

Drop files here or

Max. file size: 2 MB.

Results of diagnostic tests*

Drop files here or

Max. file size: 2 MB.

Medical report*

Drop files here or

Max. file size: 2 MB.

PAYMENT OF CLAIMS

Turnberry reserves the right to negotiate a discounted rate with your relevant medical service provider(s) in exchange for direct payment to them.

Please advise if you have paid your medical service provider(s)*

Yes
No

BANK DETAILS OF THE PRINICIPAL INSURED

Account holder's Full Name*

Name of Bank*

Branch Code*

Account Number*

Type of Account*

Cheque
Savings
Transmission

By checking this box, you confirm that the above information is correct.*

I declare that the banking details provided are correct, failing which, Turnberry is not liable for any losses, charges and expenses. I accept that it is my responsibility to notify Turnberry timeously of any changes in my banking details. The indemnity payment may give rise to a potential Output Tax liability under section 7(1)(a) read with section 8(8) of the Value Added Tax Act. Declaration by the Principal Insured person.

DECLARATION BY THE PRINICIPAL INSURED

By checking this box, you confirm that you have read and agree with these terms.*

I warrant that I am legally entitled to receive the benefits in terms of the said policy. Turnberry shall not be liable for payment if the cause of accident/illness is related to an exception detailed in the policy document and any endorsements thereto. In support of a claim in terms of the said policy, I declare that all statements and answers which may now or at any time be given in connection with this claim, whether in my handwriting or not, are true and complete. I understand that any misstatement or non-disclosure, which materially affects the assessment of this claim, will entitle Turnberry to declare this claim null and void. I hereby authorise the patient’s Medical Scheme, any Hospital, medical service provider or any other person who has attended to or examined the patient, to furnish to Turnberry or Turnberry’s authorised representative any information with respect to any illness or injury, medical history, consultations, prescriptions or treatment and copies of all hospital or medical records. A copy of this authorisation shall be considered as effective and valid as the original. Should any benefit be paid by Turnberry and subsequently settled, in whole or part, by the patient’s Medical Scheme or the medical service · provider/s reduced the amount they have charged, the amount of the overpayment will be refunded to Turnberry.

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Claim Form

Complete the form below to begin filing your claim.

DETAILS OF PRINCIPAL INSURED PERSON

MEDICAL AID INFORMATION

DETAILS OF PATIENT

TREATMENT DETAILS

BENEFIT YOU WOULD LIKE TO CLAIM FOR

PAYMENT OF CLAIMS

BANK DETAILS OF THE PRINICIPAL INSURED

DECLARATION BY THE PRINICIPAL INSURED