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Claim Form
Claim Form
Wendy
2020-12-18T14:07:09+00:00
Complete the form below to begin filing your claim.
Policy Number or ID Number of Principal Person Insured
*
DETAILS OF PRINCIPAL INSURED PERSON
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
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
*
Hospital
Day Clinic
Doctors rooms
Casualty/Emergency Room
Other
Please specify
*
Treatment date/ Date of admission
*
Date Format: DD slash MM slash YYYY
Date of Discharge
*
Date Format: DD slash MM slash YYYY
BENEFIT YOU WOULD LIKE TO CLAIM FOR
Select the benefit you are claiming for
*
Medical Expense Shortfall Cover for Doctors
Medical Expense Shortfall Cover for Radiology / Pathology
Co-payment Cover
Non-DSP Hospital Penalty Cover
Sub-limit Cover
Traditional Cancer Cover
Biological Cancer Drug Benefit
Casualty Benefit (Only the emergency rooms at a hospital qualifies for the Casualty Benefit)
Cancer Diagnosis Benefit
Medical Scheme Contribution Waiver and Gap Premium Waiver
Personal Accident Benefit
Critical Illness Benefit
I am not sure which benefit my claim falls under
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
Medical Aid Claims Statement
*
Drop files here or
Full Hospital account
*
Drop files here or
Hospital account/Day Clinic Account/Radiology account
*
Drop files here or
Hospital account / Day Clinic Account
*
Drop files here or
Hospital account / Day Clinic Account / Radiology Account / Doctors Account / Pathology account
*
Drop files here or
Hospital account / Day Clinic Account / Radiology Account / Doctors Account / Pathology account/ Pharmacy accounts
*
Drop files here or
Accounts for the Biological Cancer Drug (Pharmacy)
*
Drop files here or
Casualty account
*
Drop files here or
Doctors and/or Radiology accounts
*
Drop files here or
Histology report
*
Drop files here or
Report from Oncologist
*
Drop files here or
Treatment plan
*
Drop files here or
Medical report stating the disability
*
Drop files here or
Proof of the Medical Scheme Contribution Payer (bank statement or letter from Medical Scheme)
*
Drop files here or
Medical Scheme Certificate reflecting the contribution
*
Drop files here or
Death Certificate
*
Drop files here or
Executorship Letter or Letter of Authority
*
Drop files here or
Needs to be on the relevant letterhead
Estate Banking Details
*
Drop files here or
Please note it needs to be on the relevant banks letterhead
Police report
*
Drop files here or
Police report
*
Drop files here or
Results of diagnostic tests
*
Drop files here or
Medical report
*
Drop files here or
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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