Internal Seriti Claim Form

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Gap Cover - Post Treatment or Procedure Claim

To claim against your Cinagi gap cover benefits you need to complete this form and attach all the relevant claim documents once prompted.

The supporting documentation that will required is as follows and can be uploaded online while completing this form:

The relevant account from the doctor/provider
The claims statement from the medical scheme showing how they have processed and paid the above account
The first 2-3 pages of the hospital account showing the admission/discharge dates, ICD-10 codes, patient name, etc (if applicable)

Claims are processed continuously and are paid daily.

Once we have finalised your claim we will issue you with a claim remittance via e-mail.

Important : Cinagi can’t start with the assessment of your claim until we have received a fully completed claim form and all the relevant supporting documentation.

You can contact us if you need any assistance by clicking HERE .

Policy Holder Details

Initials*

Name*

First Last

ID or Passport Number*

Cellphone Number*

Email*

Enter Email Confirm Email

Medical Scheme*

Benefit Option*

Membership Number*

Cinagi Policy Number (If Available)

Patient Details

Name*

First Last

Date of Birth*

Gender*

Male

Female

Relation to Policy Holder

Details of Medical Service Providers

Name of Doctor*

Telephone Number*

Practice Number*

Treatment Date*

Name of Hospital (if applicable)

Please provide details or description of the illness & treatment*

File*

Drop files here or

Max. file size: 2 GB, Max. files: 15.

Payment Details

Where applicable, we will pay your doctor directly. If you have already paid your doctor, we will refund you.

Bank Name*

Enter Bank Name

Account Holder Name*

Account Type*

Account Number*

Branch Code*

Declaration & Submission

I hereby provide explicit consent to Cinagi (Pty) Ltd, its subsidiaries, associates, sub-contractors and/or its underwriters to:

Use my personal information and all the information relating to this claim in order to provide me with administrative and insurance services; and
Negotiate with my medical service providers on the fees that they have charged; and
Engage with my medical service providers on whether their fees are compliant with prevailing legislation; and
Disclose information to persons and entities that it is necessary to disclose this information to in order to provide me with the aforementioned services; and
Communicate with me electronically about any changes or general information relating to administrative processes or changes to my policy, benefits, benefit costs and/or claims processes; and
Transfer my personal information outside South Africa if I have provided an email address that is hosted outside South Africa or to administer certain services, for example, cloud services; and
Obtain any medical records, medical claims or personal information of myself or my dependants from my/our medical scheme and/or my/our medical service providers, including their sub-contractors who process or transfer the relevant medical records, medical claims and/or personal information; and
Obtain any medical records, medical claims or personal information for myself or my dependants from any medical data bureau or credit bureau who respectively act as aggregators of medical and credit information.

I further agree and confirm that:

All details supplied in this form and the supporting documentation are true and correct; and
I am aware that any non-disclosure or misrepresentation may result in this claim being rejected or my policy cancelled or voided from inception; and
By submitting my dependents’ personal information, I hereby confirm that I am authorised to share such information; and
If I am submitting this claim for a dependent under the age of 18 years (a minor), I confirm that I have the authority to act on their behalf.

You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement, which can be found here: Privacy Statement .

Signed At*

City Province

Signature*