Broker Assistant

Cinagi offers two gap cover products in 2027:

• GapMAX – comprehensive in-hospital and oncology gap cover with extender benefits, available to private individuals and employer groups. Download the GapMAX 2027 brochure
• GapSELECT – all the core GapMAX benefits plus out-patient benefits (specialist, GP and dentist consultations), medicines on in-patient doctor accounts, dental reconstruction and a sub-acute facility benefit. Download the GapSELECT 2027 brochure

Both products are underwritten by Infiniti Insurance Limited and include Wellniciti, Cinagi’s wellness and financial rewards programme.

Both products provide Total Cover Enhancement on the shortfall between the medical scheme benefit and the amount charged by:

• Medical specialists for treatment or surgery provided in hospital
• Medical oncologists for treatment provided in or out of hospital
• Medical specialists for out-patient procedures that would otherwise attract a co-payment if performed in hospital

This cover applies to the accounts of the individual practitioners. Shortfalls on hospital, day clinic, step-down facility and diagnostic (pathology and radiology) accounts are excluded, other than the co-payments and upfront payments shown in the benefit schedule.

All gap cover benefits are subject to the overall annual limit (OAL) of R226,800 per insured person, which automatically increases from 1 April 2027 in line with CPI. Claims can only be paid where a shortfall exists between the medical scheme benefit and the amount charged.

We cover shortfalls on gynaecologist and/or paediatrician consultations from the 2nd trimester to 90 days post-delivery:

On GapSELECT, maternity consultations form part of the combined R10,000 per policy per annum out-patient limit.

All oncology cover categories include treatment using new generation biologicals and immunotherapies (precision medicines) approved by the medical scheme, including the 25% or 50% co-payments applied on precision cancer medicines.

We do not cover oncology shortfalls where a member exceeds a benefit limit applied by their medical scheme, or where certain cancer types are excluded by the medical scheme.

Our Claim Optimiser can pay an upfront payment directly to the hospital so that the member is not out of pocket. Contact us at least 72 hours before the admission; this service is not available while the policy is still subject to a waiting period.

GapSELECT includes all of the benefits above, plus:

Casualty cover is limited to 3 events per policy per annum.

• Accident cover applies only to emergency treatment at a casualty facility within 12 hours of the accident, for x-rays, blood tests, medicines and the fees of attending doctors.
• After hours means Monday to Friday between 6pm and 6am, plus any hours over a weekend or public holiday.
• Appliances, prosthetics and any treatment after the initial visit to the casualty facility are excluded.

If the casualty visit was the result of a sports injury, we also cover shortfalls on rehabilitation consultations with a physiotherapist, biokineticist or chiropractor: R850 per consultation, up to 6 consultations per event.

We cover the excess on the member’s international travel insurance for medical emergencies while travelling outside South Africa: R4,200 per departure.

A once-off lump sum is paid on a first lifetime cancer diagnosis made after joining and after all waiting periods have expired:

• Skin cancer is excluded (except melanomas of stage 2 or more) and the benefit ceases at age 65.
• To qualify as a first lifetime diagnosis there must have been no previous form of cancer, including skin and in-situ.
• If the member upgrades their medical scheme benefit option at the first opportunity after diagnosis, we cover the additional medical scheme contributions: R5,600 per month for up to 12 months. The upgrade must be to the richest option on the scheme or another option agreed by Cinagi, and the benefit stops if the member downgrades within 12 months.

If the same event causes two insured lives on the same policy to be admitted to hospital, only the insured with the longest admission attracts the daily benefit.

A lump sum of R36,000 is paid on the accidental death or permanent disability of an insured. If the event is a direct result of a proven crime, the benefit doubles. Limited to 2 insured persons per event.

On the accidental death or permanent disability of the principal member or spouse, we pay the medical scheme contributions (up to R8,600 per month) and 100% of the gap cover premiums for 6 months.

If an insured is a witness to or a victim of a violent crime, we cover sessions with a counselling therapist: R1,000 per session, up to R11,000 per policy per annum.

We aim to offer you and your client the best rates possible, so we do a risk assessment of the demographic profile of your client. Please send us the following for each eligible member:

• Date of birth or age of the principal member
• Medical scheme
• Medical scheme benefit option
• Number of spouse dependants
• Number of child dependants

Send this information to quotes@cinagi.co.za.

Whether a member is a private individual or part of an employer group, they can join using the Cinagi online application. Joining online takes less than 3 minutes.

Once an employer group has accepted the quote, the employer completes the Cinagi employer application. We then set up the group account and send a welcome letter to the nominated contact persons explaining the monthly billing and other administrative processes.

In accordance with regulations, private members are community rated together and pay according to our benefit cost table in the GapMAX 2027 brochure. Benefit costs are based on the entry age of the oldest person on the policy, family size and the medical scheme benefit option. GapMAX starts at R288 per month in 2027 – see the full 2027 rate table or use our cost calculator. Group schemes of fewer than 25 members are rated on the same table.

Cover Pay Level (CPL) – the percentage of the medical scheme tariff at which the member’s benefit option reimburses in-hospital medical specialists. Members on an option reimbursing at 200% or more pay the CPL-200 rates; members on an option reimbursing at 100% pay the CPL-100 rates.

Members must notify us of any benefit option changes in case their CPL needs to change. If a member is on CPL-200 but their option covers at 100% of scheme tariff, there may be a shortfall on gap cover claims for specialists. If we are not notified of a CPL change, membership will not be backdated and benefit costs will not be refunded.

Eligibility – only a spouse (including a common-law spouse or life partner) and children (including stepchildren, adopted, foster and special-needs children) are eligible, and all insured persons must be covered under the same medical scheme membership. The main member can be the principal member of the medical scheme or their spouse. Other beneficiaries on the medical scheme (e.g. parents) need a separate policy.

Children – a maximum of two children are charged at child rates until they turn 27. From age 27, all children are charged adult rates. For example, if there are three children under 27 on a policy, only two are charged; when the oldest turns 27, two are charged the child rate and the oldest the adult rate.

The rates include VAT, broker commission, administration fees and the Wellniciti fee. Rates are adjusted on 1 January each year in line with medical inflation.

Commission on Cinagi gap cover products is calculated in line with the table below:

Example: Mr A has a Cinagi gap cover policy with a monthly cost of R520. The commission payable is (R300 × 20%) + (R220 × 15%) = R93.00.

Commission is paid on the 15th of each month for all receipts during the previous month. For example, commission on premiums received from 1 to 31 January is paid on 15 February, or on the first working day thereafter if the 15th falls on a weekend.

Yes. Statements are sent to the e-mail address of the commission contact person you provided on your intermediary application. For any commission queries, e-mail commissions@cinagi.co.za.

Members can submit their claim online and upload the supporting documents on the Cinagi claim form or through the member portal. Members are guided on which supporting documents are required.

Claims are processed within 48 hours of receiving all supporting documents.

With InstaClaim, South Africa’s first “60-minute” gap cover claims process, qualifying claims are processed in under 60 minutes and paid instantly into the member’s bank account. InstaClaim is 100% digital and requires no paperwork.

Yes. If an upfront payment is required before a hospital admission, our Claim Optimiser guarantees the payment directly to the hospital, so the member is not out of pocket. Contact us at least 72 hours before the admission. This service is not available while the policy is still subject to a waiting period.

• The relevant account from the doctor or provider.
• The claims statement from the medical scheme showing how the account was processed and paid (it can be downloaded from the scheme’s website or app).
• For hospital admissions, the first 2–3 pages of the hospital account showing the admission and discharge dates, ICD-10 codes and patient name.
• For casualty cover claims, only the account from the casualty practice and the medical scheme claims statement are required.

Claims must be submitted within 4 months of the date of treatment.

If documentation is outstanding, the member receives a notification from us listing exactly what is still needed, with a link to upload the outstanding documents.

No. To ensure the best client experience, all our forms are submitted online.

Members can message us on WhatsApp (060 070 2310) or submit a query on our contact form. If a member would prefer to speak to someone, a call can be scheduled with one of our consultants.

An employee joins the group scheme by completing the online application. The employee provides their employer’s details on the application so that we can allocate them to the correct group.

Membership can only start on the 1st day of a month.

1. By the 15th of each month, Cinagi issues a listing of the members covered under the group scheme.
2. The employer confirms that the listing is correct, or indicates any resignations on the attached spreadsheet. New members are added through the online application – employees who apply on or before the 14th appear on that month’s listing; those who apply after the 14th join from the 1st of the following month.
3. The updated spreadsheet must be returned to billing@cinagi.co.za by replying to our e-mail of the 15th, no later than the 24th of the month. Please do not change the subject line – it contains the reference code that links the e-mail to your account.
4. We issue the billing statement on the 27th of the month.

Once the employer application is received and the group is activated, we send a welcome letter with the payment reference and the detailed billing process. The banking details of Infiniti Insurance Ltd are attached to the welcome letter and can also be downloaded here.

1. WhatsApp (060 070 2310) – the Cinagi client service bot first tries to assist with basic queries. If it cannot help, the conversation is routed to one of our service consultants.
2. Schedule a call – members who prefer to speak to a consultant can book a call at a convenient time, which allows us to prepare beforehand and give the best possible service.
3. Contact page – queries are routed according to their nature and the member receives a confirmation e-mail.

• Submit a claim online with the supporting documents.
• Update their details – contact and debit order details, medical scheme cover, and adding or removing policy dependants.
• Get a copy of their policy document and/or a confirmation of cover.

Appropriate and accurate underwriting is important to manage the anti-selection risk that the insurer faces, and to be fair to existing members in the risk pool. Waiting periods are applied in line with regulations.

The membership application includes three underwriting questions. Please advise prospective clients to answer them accurately and honestly to avoid claims being rejected or policies being cancelled.

• A 3-month general waiting period applies to all claims except accidents. The Cancer Diagnosis and Travel Cover benefits are also subject to the 3-month waiting period.
• A 12-month waiting period applies to claims directly or indirectly related to scopes (including minimally invasive scopes, endoscopies, arthroscopies and hysteroscopies), endometrial ablations, hysterectomy, pregnancy and childbirth, cholecystectomy, wisdom teeth, dental treatment, cataracts, reflux surgery, tonsillectomy, grommets, adenoidectomy, nasal procedures, hernia procedures, joint replacements and spinal surgery.
• A 12-month waiting period applies to any pre-existing condition at policy inception, and to any condition for which advice, diagnosis, care or treatment was received or recommended in the 12 months before inception.
• Waiting periods also apply to new dependants added after inception.

• New members on voluntary groups and private individuals – both the 3-month general and 12-month condition-specific waiting periods apply, unless proof of previous cover is provided (see members with previous cover below).
• Existing voluntary groups transferring – for groups of at least 25 members, all waiting periods are waived.
• Compulsory groups – for groups of at least 25 members, all waiting periods are waived, including for new members joining when they become eligible. This applies only where Cinagi is the employer’s sole gap cover provider; if the employer makes another gap cover provider available, Cinagi may impose waiting periods on future members.
• Continuation members – an employee who leaves a group with waived or reduced waiting periods and wants to continue cover must complete a new Cinagi online application and select option 4 under ‘Application Status’ at the top of page 2. The application is re-assessed as a private individual, taking the previous duration of cover into account, and rated on the private individual table. Cinagi may impose a 3-month general waiting period.
• Members with previous cover – if a member joins from another gap cover provider within 90 days of the previous cover ending, the 3-month general waiting period and/or the unexpired portion of any 12-month waiting period may apply. If the member had the previous cover for more than a year, no part of the 12-month waiting period applies. This only applies if the previous benefits were materially similar to Cinagi’s; otherwise the full 12-month waiting period may apply.

• Treatment excluded by the medical scheme – gap cover can only cover shortfalls on medical costs that the scheme covers.
• Claims where the scheme has limited the benefit or imposed co-payments because it does not recognise the clinical efficacy or validity of the procedure or treatment.
• Specialised dentistry or elective maxillofacial surgery (e.g. bridges, implants, frenectomy, orthognathic surgery). Basic in-hospital dentistry, such as wisdom teeth extractions or fillings for young children, is covered.
• Co-payments, deductibles or limitations applied as a penalty for not following scheme rules or for voluntary use of a non-network provider (other than the non-network hospital upfront payment benefit in the benefit schedule).
• Weight-loss or bariatric surgery, obesity (including related modifier codes), infertility and sleep studies.
• Claims submitted more than 4 months after the date of treatment.
• Claims not recognised as medically necessary or paid as an ex-gratia or concession (except the oncology ex-gratia benefit).
• Experimental, unproven or unregistered treatments, medicines or practices.
• Claims incurred outside South Africa (except Travel Cover).
• Claims arising from a provider and/or medical scheme not complying with prevailing legislation.
• Shortfalls on hospital accounts, day clinics, step-down facilities or diagnostic services (pathology and radiology), other than the co-payments and upfront payments in the benefit schedule.
• Casualty cover outside its conditions – accident cover applies only within 12 hours of the accident and child illness cover only after hours; appliances, prosthetics and follow-up treatment are excluded.

This policy is not a medical scheme and the cover is not the same as that of a medical scheme. It is not a substitute for medical scheme membership.

Wellniciti is a separate loyalty product sold and administered by Cinagi. Its cost is automatically included in the monthly Cinagi benefit cost. It offers:

• Grocery savings at Shoprite, Checkers and Checkers Hyper – members message 065 753 1916 on WhatsApp, select “Grocery Savings” (option 2) and sign in with their ID number, or use www.wellniciti.co.za. Savings apply over and above in-store promotions.
• Healthcare savings – reduced consultation fees with primary healthcare providers, including R200 virtual GP consultations. Members log in at www.wellniciti.co.za and select “Book a Virtual Consult” or “Find a Healthcare Professional”.
• Financial wellbeing – confidential one-on-one telephonic coaching on budgeting, debt, credit health and major financial decisions.

Read more about Wellniciti