Members can submit their claim online and upload the supporting documentation at Cinagi Claim Form. Members will be guided as to what supporting documents are required.

From the time we have received all the supporting documents from the member, claims are processed within 48 hours.

If there is outstanding documentation, the member will receive a notification from us detailing exactly what is still outstanding, with a link that can be used to upload the outstanding document/s.

In order to ensure the best client experience, we have placed all our form submission online.

The supporting documentation required are:

  • The relevant account from the doctor/provider.
  • The claims remittance 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)
  • For claims against the Casualty Benefit, only a copy of the account from the casualty practice and the claims remittance from the medical scheme are required.

Members can message us on our Whatsapp number (060 070 2310) or submit a query on the contact form on our website.

Should a member wish to speak to someone, a call can be scheduled with one of our consultants.

The 4 benefit categories listed under ‘Gap Cover Benefits’ (also known as medical expense shortfall benefits) are collectively subject to the overall statutory limit of R172,000 per insured person on the policy for 2021. In accordance with the demarcation regulations, this limit will increase by CPI each year.

 

An additional 500% cover is provided over and above the medical scheme tariff for approved oncology and in-hospital procedures/treatment.

This cover only applies to the individual practitioners providing their in-patient services. Any additional charges from the hospital or facility are excluded.

The 20% co-payment that arises after the oncology threshold is reached. This only applies to certain options on Discovery and Momentum medical schemes.

Cover applies to treatment approved by a member’s medical scheme for either traditional chemotherapy or modern biological drugs.

(Note: 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).

 

Where fixed value upfront payments are required for the following in-hospital treatment:

  • Endoscopes
  • Specialised scans (MRI/CT/PET)
  • Basic dentistry (eg fillings for young children, wisdom teeth extraction)
  • Surgical procedures defined by a medical scheme (eg Priority plans)
    (Note: where schemes apply upfront payments (including co-payments and/or deductibles) as percentages of the treatment cost, the policy benefit is limited to a maximum of R10,000 per event).

If a co-payment is applied for involuntary use of a non-DSP hospital or day clinic, we will cover one such co-payment per
annum per policy, subject to a maximum of R10,000.

We provide extra cover when benefit limits apply on internal prosthetic devices to a maximum of R38 000 per procedure.

Below is a summary of the benefit categories under Extender Cover.

Each benefit category below has its own limitation, and these are not subject to the overall statutory limit on the gap cover benefits.

Cover for emergency treatment at a casualty facility resulting from an accident.

There is no limit on the number of events per annum but the limit per event is R12,500.

Note :Benefits only apply for treatment received within 12 hours of the accident and excludes cover for specialised radiology scans and prosthetic devices.

If after claiming on the Casualty Cover above, the accident occurred during practice or a social sporting event, shortfalls on rehabilitative consultations (physiotherapy or chiropractic) will be covered up to R420 per consult for a maximum of 6 consultations.

This cover is limited to one event per year and the consultations must occur within 6 weeks of the accident.

Covers the excess on international travel insurance claims for emergency events while travelling outside of the country.

There is no limit on the number of events annually but there is a limit of one event per international outbound trip subject to a maximum claim of R2,100.

On a first-time diagnosis of an insured with cancer that is classified as stage 2 or higher, a lump sum benefit of R29,000 is payable.

This is a once-off lifetime benefit and the first-time diagnosis must occur after the 3-month general waiting period – any diagnosis prior to that does not qualify.

Note : This benefit excludes all skin cancers except malignant melanoma.

This benefit activates on a hospital admission that lasts 3 days or longer and resulted from an accidental event or a delivery/birth that is 42 days (6 weeks) or earlier than the original due date.

The benefit is payable from the 1st day in hospital up to a maximum of 28 days per event, as follows:

  • Tier 1 pays from day 1 - 7 at R105 per day

and

  • Tier 2 pays from day 8 – 28 at R1050 per day.

Note :If the same event causes two insured lives from the same policy to be admitted to hospital, then only the insured with the longest admission attracts a benefit, eg a birth of multiple premature infants only qualifies as a single event.

In the event of accidental death or permanent disability of an insured, a lump sum of R25,000 is paid if the insured is an adult (21 years or more) and a lump sum of R12,500 is paid if the insured is younger than 21 years.

If the principal member of the medical scheme membership covered under the policy is deceased or permanently disabled from an accident, the medical scheme contributions will be covered up to a maximum of R5,200 per month for 6 months.

The Cinagi Gap Cover premiums will be waived for 6 months.

If you are diagnosed with a serious illness, Mediguide International’s global panel of World Leading Medical Research Centres gives you access to the world’s top medical minds for a diagnosis review.

This ensures that your diagnosis is 100% accurate and your treatment plan is optimally structured for you to achieve the best possible health outcome.

Click here if you would like to find out more about Medical Second Opinion. 

Commission on on Cinagi Gap products are calculated in line with the table below :

Monthly premium band Maximum Commission Level
Above R1,200 5%
R601 to R1,200 10%
R300 to R 600 15%
Less than R300 20%

Example:

Mr.A has a Cinagi Gap Cover policy with a premium of R520 per month. The commission payable is equal to the below :

(R300 x 20%) +(R220 x 15%) = R93.00

Commission will be paid on the 15th  each month for all receipts during the previous month.

Example :

All commissions relating to policy premiums received during January (1 Jan – 31 Jan) will be paid on 15 February or the first working day there after in the event that the 15th falls over a weekend.

Yes, when completing your intermediary application you would have provided us with the email address of the contact person responsible for commissions, we will use this address to send all commission statement to.

If you have any queries or concerns to your commissions you can send a email to : commissions@cinagi.co.za

Our policy includes certain exclusions to protect against unnecessary losses and ensure long-term sustainability.

We list below the most salient of the exclusion types but encourage you to familiarise yourself with the full list of exclusions contained in Section D of the policy document :

  • CLAIMS NOT COVERED BY THE MEDICAL SCHEME – in line with the demarcation regulations, a gap cover policy may not cover any claim for treatment that is excluded by a medical scheme.
  • EX-GRATIA CLAIMS - any claims that are paid by a medical scheme on an ex-gratia or concessionary basis are excluded.
  • DAY-TO-DAY CLAIMS - unless shown as a specific benefit in the benefit table, day-to-day claims are not covered.
  • CO-PAYMENTS APPLIED AS A PERCENTAGE – under the ‘Upfront Payments’ category of gap cover benefits, any upfront payments, co-payments or deductibles that are applied against the scheme benefits as a percentage of costs are limited to a maximum benefit of R10,000 per event. Only upfront payments, co-payments or deductibles that are defined in rand value within the medical scheme rules are covered in full.
  • PENALTY AMOUNTS – any amount required to be paid by a medical scheme member for non-adherence to the scheme’s rules or pre-authorisation procedures are excluded from cover.
  • SPECIALISED IN-HOSPITAL DENTISTRY – claims for bridges, implants, crowns, orthognathic surgery, frenectomies are excluded. This does not apply to basic in-hospital dentistry, eg fillings for young children, surgical wisdom teeth extraction.
  • UNAPPROVED TREATMENT - Any claim excluded by your medical scheme or where the hospital admission or treatment was not approved by your medical scheme.
  • PROVEN EFFICACY - Any claim for which your medical scheme has limited the benefit or imposed co-payments because the scheme does not recognise the clinical efficacy or validity of the related procedure or treatment.
  • ONCOLOGY - Any co-payment for oncology treatment other than the 20% co-payment applied once oncology costs have
    reached pre-defined thresholds of your benefit option.
  • WEIGHT LOSS - Any claim relating to weight-loss treatment or bariatric surgery.
  • LATE CLAIMS - Any claim submitted more than 4 months after date of treatment.
  • UNREGISTERED TREATMENTS – any experimental, unproven or unregistered treatments, medicines or practices are excluded from cover.
  • TERRITORY - Any claim arising from an event that occurred outside of South Africa (excl Travel Cover).
  • CASUALTY COVER - applies only to care received at an out-patient casualty facility within 12 hours of an accident. The
    benefit excludes claims for appliances, materials, prosthetics, specialised radiology and any subsequent treatment after
    the initial visit to the casualty facility.
  • SPORTS COVER - is provided subsequent to a Casualty Cover claim where the event that gave rise to the claim occurred
    during a sports activity (can be social activity or part of an organised event). The benefit is limited to one event annually
    and covers up to 6 physiotherapy or chiropractic consultations within 6 weeks of the accident, up to a maximum of R420
    per consultation.

We would like to offer you and your client the best premiums possible. In order to do so we do an risk assessment of the demographic profile of your client.

To do this risk assessment we require that you submit various demographics for each eligible member, this includes :

  • Date of Birth or Age of principal member
  • Medical Scheme
  • Medical Scheme Benefit Option
  • Number of Spouse Dependents
  • Number of Child Dependents

This information can be sent to : quotes@cinagi.co.za

Whether a member is a private individual or part of an employer group, they can join by making use of the Cinagi Online Application :

Online Application

Once an employer group has accepted the quote, the employer can complete the Cinagi Employer Application.

This will provide us with all the necessary details to setup the group account, whereafter a welcome letter will be issued to the nominated contact persons at the company explaining the monthly billing and other administrative processes.

In accordance with regulations, private members will all be community rated together and pay according to the premium table below (you can make use of our premium calculator  )

Group schemes of less than 25 members will also be rated the same so the premium table below will apply to such groups.

Cover Pay Level (CPL) – this is the percentage of the medical scheme tariff at which a member’s benefit option reimburses in-hospital medical specialist treatment.

Members on a benefit option reimbursing at 200% (or higher) will pay the CPL- 200 premiums. Members on a benefit option reimbursing at 100% will need to pay the CPL-100 premiums.

NOTE: It is important that members notify us any benefit option changes they make on their medical scheme in case
they need to also change the CPL. If a member is on the CPL-200 policy but is on a benefit option covering at 100% of the
scheme tariff, then there may be a shortfall on gap cover claims for specialists. If we are not correctly notified of a CPL
change, membership will not be backdated nor will premiums be refunded.

Eligibility - Please note that only the following dependent types are eligible for cover under the policy:

  • a spouse – this includes a common law spouse or life partner
  • Children – this includes stepchildren, adopted children, foster children or special needs children.

All insured persons under the policy must be covered under the same medical scheme membership.

The main member (applicant) on the policy can be either the principal member of the medical scheme membership or the spouse of the principal member – as long as all dependents registered on the policy are covered under one medical scheme membership. Other beneficiaries registered on the applicant’s medical scheme (eg parents) would need to take out a separate policy.

Dependent Premiums - a maximum of two children are charged for at child rates up until they turn 24. From age 24, all children are charged as adult dependents.

Example: If there are three children on a policy and they are all under 24, then the only charge for children will be
two child premiums. When the oldest child turns 24, then there will still be two child premiums charged plus one
new adult premium.

Click here if you would like to find out more about Medical Second Opinion. 

An employee wishing to join the group scheme can do so by completing the online application.

When completing the application the employee will be asked to complete the details of his employer which will allow us to allocate accordingly.

The inception date of the employee’s membership on the group scheme will depend on the date that the employee completes the application form, as follows:

Employee Submits Application:  Inception Date 
On or before the 14th day of a month The 1st of the same month
After the 14th day of a month The 1st of the following month
Membership can only commence on the 1st day of a month.

Cinagi will issue a listing by the 15th of each month showing which members are covered under the group scheme.

We then require confirmation that the member listing provided is correct or an indication on the attached spreadsheet of any resignations.

New additions to the group scheme are managed through the online application form (as per section 1 above) – if the application form was completed by an employee on or before the 14th of the month, then they will appear on the member listing that we issue for that month.

If the member completes the application form after the 14th of the month, then they will only be permitted to join from the 1st of the following month.

The updated spreadsheet must please be returned to billing@cinagi.co.za by reply on the e-mail we sent on the 15th – this needs to reach us by no later than the 24th of the month.

Note : Subject line of this e-mail is not to be changed as it contains a reference code to link to your account to our systems.

We will then issue the billing statement on the 27th of that month.

On receipt of the employer application and subsequent activation a Welcome letter will be issued directly to the employed containing the payment reference along with the detailed billing process.

Also attached to the Welcome Letter will be the banking details of Infiniti Insurance Ltd. This can also be downloaded here.

All existing policy holders can get in touch with us through any of the below channels :

  1. WhatsApp Text Messenger (060 070 2310): When sending a message, the Cinagi client service bot will first try and assist for basic queries. Should the bot not be able to provide the necessary assistance, the conversation will be routed to one of our service consultants.
  2. Schedule-a-call :  Should a member prefer to speak directly with one of our service consultants, they can schedule a call at a convenient time by make use of our Call Scheduler. This allows us to do all the necessary screening and preparations beforehand, which allows us to provide each member with the best possible service at point of engagement.
  3. Contact Page : All queries logged though our contact page will be routed accordingly based on the nature of the query. On submission the member will receive a confirmation email.

Appropriate and accurate underwriting are important in order to manage anti-selection risks that the insurer faces as well as
to be fair to the existing members in the risk pool.

Three underwriting questions are included within the membership application. It is important to advise prospective clients of the importance of answering these as accurately and honestly as possible to avoid possible claim rejections or policy cancellations.

The application of waiting periods on the gap cover benefits of the policy is guided by regulations.

A 3-month general waiting period and a 12-month condition-specific waiting period is permissible.

  • The 3-month waiting period applies to all gap cover benefits, excluding claims arising from accidental events. The Cancer Diagnosis and Travel Cover benefits also have a 3-month waiting period.
  • The 12-month waiting period applies to any condition for which medical advice, diagnosis, care or treatment was
    recommended to or received by an insured within a period of 12 months before entering into the policy.

Both the 3-month general waiting period and 12-month condition specific waiting period will always be applied to
these categories of members unless proof of previous cover can be provided.

For more information on how waiting periods are applied to members who had previous cover see section "Waiting Periods for members with previous cover"

 

For a group size of at least 25 members, all waiting periods will be waived for this category of members.

For a group size of at least 25 members, all waiting periods will be waived for this category of members.

Waiting periods will also be waived for new members joining the compulsory group when they become eligible to join.

Note

This will only apply to groups where Cinagi is the only gap cover provider to that employer – if the employer creates a split-risk arrangement by making another gap cover provider available to their staff, Cinagi reserves the right to impose waiting periods on future members joining such a group.

If an employee is part of a group scheme arrangement with waived or reduced waiting periods and resigns from the group and wishes to continue with cover, they will be required to complete a new Cinagi online application and select option 4 under ‘Application Status’ at the top of page 2.

This application as a private individual will then be re-assessed by our underwriting team, taking into account the previous duration of cover under the group scheme. The new policy premium will also be rated according to the table applicable to private individuals.

Cinagi further reserves the right to impose a 3 month general waiting period on such policies based on our underwriting criteria.

 

If a member is joining from another gap cover provider and does so within 90 days of the previous cover ceasing, the balance of any unexpired portion of the 12-month waiting may be applied.

If the member had been on the previous cover for more than a year, then no portion of the 12-month waiting period will be applied.

It is important to note though, that this only applies if the previous gap cover policy had benefits that were materially similar to Cinagi Gap Cover benefits. If the previous gap cover benefits were not materially similar, then the full 12-month waiting period may be applied.

Cinagi further reserves the right to impose a 3 month general waiting period on such policies based on our underwriting criteria.