TruGap Application Form

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TruGap Gap Cover for Momentum

Online Application Form

What happens once you submitted this form?

Once you have submitted the application form, your details and Medical Aid membership will be verified. If there are any problems, we will get in touch with you. If all is in order, you will receive a welcome email with your Gap Cover membership Certificate.[/vc_column_text][/vc_column][/vc_row][vc_row height="auto"][vc_column][vc_column_text]

SECTION 1: PERSONAL DETAILS
SECTION 2: BENEFICIARY DETAILS
SECTION 3: PRODUCT SELECTION
SECTION 4: DEBIT ORDER DETAILS
SECTION 5: GAP COVER WAITING PERIODS
  • General waiting period: There is no general 3 month waiting period.
  • 10 Month condition specific waiting period: No claims may be submitted within the first 10 months of membership for any Gap Cover policy if they relate to any of the following conditions:
    • Head, neck and spinal procedures (including stimulators) e.g. laminectomy
    • Recurrent hernia repair/s
    • Endoscopic procedures e.g. colonoscopy, gastroscopy
    • Pregnancy and childbirth
    • Gynaecological conditions e.g. Hysterectomy
    • Joint replacement (including arthroplasty, arthroscopy and metatarsal osteotomy) but excluding treatment due to accidental trauma
    • Inability to walk / move without pain
    • Nasal and sinus
    • Cardiac (relating to the heart)
    • Dentistry (unless due to accidental trauma)
    • Cataracts and / or eye laser surgery
    • Neurological conditions and procedures (including stimulators)
    • Organ transplants (including cochlear implants)
    • Reconstructive surgery as a result of an incident or condition that occurred prior to membership (including skin grafts)
    • Mental health or psychiatric conditions
  • The above conditions may be reviewed for appeal at medical management discretion within the first 10 months of membership.
  • Cancer diagnosis waiting period: If a policyholder is diagnosed with any form of cancer prior to membership, all related claims will be subject to a 9 month waiting period.
  • If a policyholder has previously been diagnosed with cancer and is currently in remission, the policyholder needs to advise the insurer by way of medical evidence that the remission period has been for two or more consecutive years.
  • Pre-existing medical condition/s waiting period: no claims relating to any pre-existing condition/s (excluding cancer) will be covered within the first 6 months of membership.
  • The insurer reserves the right to request any clinical information from a policyholder’s doctor should a claim in this period indicate and /or relate to a pre-existing condition.
SECTION 6: TERMS AND CONDITIONS
  • This brochure is a summary of the benefits on offer. Please refer to the product policy document for all terms and conditions.
  • The monthly cut-off date for the receipt of application forms will be the 20th of each month (or closest working day to the 20th) to be effective from the 1st of the following month.
  • Upgrades are only allowed once a year in January.
  • Maximum entry age is 65 next birthday. Children over 21 will pay adult rates.
  • Claims relating to any penalties incurred as a result of a policyholder voluntarily choosing a provider outside of a medical scheme approved network will be excluded.
  • No in-hospital dentistry claims unless authorized by the Scheme or related to dependants under the age of 12 years. No osseointegrated dental implants will be covered.
  • Claims to the value of R500 or less will be subject to an excess of the same amount.
  • Gap Cover is distinct from, but supplementary to medical aid cover. Should you change your medical aid scheme please advise TRA for record purposes.
  • TRA requires 30 days notice of resignation from any product. Failure to advise TRA of resignation from a medical aid does not constitute a valid claim for a refund of premiums collected.
  • All documentation only available in English. Please refer to the policy document for a full list of terms and conditions.
SECTION 7: MEMBER DECLARATION and CONSENT
I have read the terms and conditions above and I am fully aware of the contents thereof.
I hereby authorise the disclosure of relevant medical information by my medical aid to Total Risk Administrators (Pty) Ltd (“TRA”) to assist in the above claims procedure. This type of information will typically include my diagnosis and ICD-10 diagnostic code. I understand and acknowledge that my medical information will not be disclosed to any unauthorised persons.
I hereby authorise TRA to deduct the amount below from my bank account, monthly in advance, for my premiums to the insurance products chosen by me on this application form. Premiums are subject to an annual review. The Insured needs to submit notice of resignation to the Insurer 30 days prior to resignation date and must be received in writing. Details of each withdrawal will be printed on my bank statement, which will enable me to identify the deduction.
Add the amounts under the product selection you made for main member and beneficiaries.
I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to TRA.
I/We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.
I hereby appoint Trulogic Financial Services as my healthcare consultant with immediate effect and understand that Trulogic Financial Services will supply me with ongoing advisory services with regard to my healthcare solutions and has access to my personal documentation.
IMPORTANT INFORMATION
Trulogic Financial Services - is an authorised financial service provider. FSP No 4263 Please send this completed form to P.O. Box 1942, Somerset West, 7129. Tel: 021 852 6740, Fax: 086 568 3065, E-mail: linda@trulogic.co.za
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