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

Step 1 of 11

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 3 times each week.

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

Important : Claim Documentation

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.

Please contact us if you need any assitance.

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Policy Holder Details
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 (If Available)

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Patient Details
Name*
First Last
Date of Birth*
Gender*
- Male
- Female
Relation to Policy Holder

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Details of Medical Service Providers
Name of Doctor*
Telephone Number*
Practice Number*
Hidden
Date of Treatment*
DD slash MM slash YYYY
Name of Hospital (if applicable)
Please provide details or description of the illness & treatment*

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Shortfall Details
To accurately assess your claim please provide us with the details of each service provider/s you would like to claim for.

Service Providers

Name of Service Provider (e.g. Doctor, Hospital)	Date of Treatment	Amount Being Claimed	Actions

There are no Entries.

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Document Upload
Upload Hospital Account*
Drop files here or

Max. file size: 5 MB, Max. files: 2.

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Document Upload
Upload the accounts from the various Doctors and/or Service Providers*
Drop files here or

Max. file size: 10 MB, Max. files: 5.

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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.
Gap Cover Claim Documents for Discovery Health Members
Please note that we cannot use the summarised statement that gets automatically e-mailed to you for processing gap cover claims. Please follow the following quick steps to download the correct document required for submitting your gap cover claim:

Step 1: Go to: https://www.discovery.co.za/portal/index.jsp and login using your username and password.

Step 2: On the top menu bar, select “MEDICAL AID”.

Step 3: At the bottom left in the drop down menu, click on “Medical Claims”.

Step 4: Click on the 3rd block that reads “Download a claims document”.

Step 5: Click on the 2nd option on the right that reads “Claims transaction history”.

Step 6: Once selected you can specify the date range in the “Transaction history criteria ” section. This range will need to include the date of when your procedure/treatment occurred.

Step 7: Once you have entered the correct dates, select “Show the results in a printable and downloadable PDF document” and then click Submit.

Your browser will then download a PDF document which you can upload to us in order to process your gap cover claim.

To view an example of the Discovery Health Claims Transaction History Report click HERE.
Upload Medical Scheme Remittance*
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 3 MB, Max. files: 3.

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

Step 1 of 11

Post Treatment or Procedure Claim

Policy Holder Details

Patient Details

Details of Medical Service Providers

Shortfall Details

Document Upload

Document Upload

The claims remittance from your medical scheme

Additional Documentation

Payment Details