Submit a Claim

Please note that you will need the following in order to complete this claim form:

A copy of the doctor’s account and the hospital account (if applicable)
A copy of the medical scheme remittance showing how they have processed the doctor’s account

1Policy Holder Details

2Claim Details

3Provider Details

4Document Upload

5Medical Scheme Statement Upload

6Payment Details

7Declaration and Submission

Post Treatment or Procedure Claim
Title*
Name*
First Last
ID or Passport Number*
Cellphone Number*
Alternative Contact Number
Email*
Enter Email Confirm Email
Medical Scheme*
Benefit Option*
Membership Number*
Cinagi Policy Number*

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Patient Details
Name*
First Last
Date of Birth*
Gender*
- Male
- Female
Relation to Policy Holder
Details of Attending Doctor
Name of Doctor*
Telephone Number*
Practice Number*
Hidden
Date of Treatment*
DD slash MM slash YYYY
Name of Hospital (if applicable)
Please provide details of the illness & treatment*

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In order to accurately asses your claim please provide us with the details of each service provider you would like to claim for.

Service Providers

Service Provider (e.g. Doctor, Hospital)	Date of Treatment	Amount Being Claimed	Actions
			Edit Delete
There are no Entries.

Maximum number of entries reached.

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Document Upload
We will need the following documentation to fully assess your claim – please upload these as indicated below.
IMPORTANT :
- Each file may be a maximum of 2MB in size.
- The hospital account (if applicable), If you only have a hard copy of the account then you only need to scan the first 2-3 pages showing the admission and discharge dates/times.
Upload Hospital Account
Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 2 MB.
Upload Doctor’s Account*
Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 2 MB.
Additional Doctor's Account
- Additional Doctor's Account
Upload Doctor’s Account*
Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 2 MB.
Additional Doctor's Account
- Additional Doctor's Account
Upload Doctor’s Account*
Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 2 MB.

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The claims remittance from your medical scheme This needs to show how they have processed and paid the above doctor’s account. This is also called the ‘claims transaction history report’ which can be downloaded by logging into your medical scheme portal and then clicking on ‘your medical claims’.
To view an example of the Fedhealth Member Statement click HERE.
To view an example of the Discovery Health Claims Transaction History Report click HERE.
Upload Medical Scheme Remittance*
Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 2 MB.
Upload any additional documentation that you may deem relevant to your claim
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB, Max. files: 7.

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Payment Details Where applicable, we will pay your doctor directly. If you have already paid your doctor, we will refund you.
Have you already paid your doctor?*
Please provide your bank account details below :
Bank Name*
Enter Bank Name
Account Holder Name*
Account Type*
Account Number*
Branch Code*
We will contact your doctor and arrange direct payment of the account – please do not settle your doctor’s account until we have processed this claim.

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Declaration & Submission
By providing the information in this form you agree that Cinagi (Pty) Ltd and its underwriter, Infiniti Insurance Ltd may :

use this information to provide you with administrative and insurance services.

negotiate with any of my medical service providers on the fees that they have charged.

disclose this information to persons and entities that it is necessary to disclose this information to in order to provide you with the aforementioned services.

communicate with you electronically about any changes or general information relating to administrative processes or changes to your policy benefits and premiums or new/upgraded services or products that are available.

only transfer your personal information outside South Africa if you have provided an email address that is hosted outside South Africa or to administer certain services, for example, cloud services and/or the Medical Second Opinion service.

You further agree that:

that all details above as well as any supporting documentation supplied with this claim, are true and correct and that you are aware that any non-disclosure or misrepresentation of any details may result in this claim being rejected or your policy cancelled or voided from inception.

•by submitting your dependents’ personal information, you hereby confirm that you are authorised to share such information with us. We will furthermore process their information for the purposes and in the manner as set out in our Privacy Statement

if you are submitting this claim for a person under the age of 18 years (a minor), you confirm that you are a competent person and that you have the authority act on their behalf.

You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement and the contents thereof.

*
I hereby acknowledge and agree to the above:
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Phone
This field is for validation purposes and should be left unchanged.

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Please note that you will need the following in order to complete this claim form:

Post Treatment or Procedure Claim

Patient Details

Details of Attending Doctor