Claims

A Guide To Claiming

Nothing is more annoying than wondering where your refund cheque is, or not knowing what you are allowed to claim for. Some of the answers to your everyday administration queries can be found in the details of your benefits structure, which is included in this document, but the majority of your queries could be eliminated by knowing the ‘’claim chain’’ at Swazimed works.

How to submit your records

  • Please mail or deliver your accounts as quickly as possible to the Swazimed address shown overleaf.
  • If you have already paid the account, attach your receipt and write ‘’paid’’ on the account. Make sure all documents sent to Swazimed show your membership number.
  • Check that your account shows:
    Your name and initials; your medical aid number; the treatment date; name of patient (as indicated on the membership card and not a nickname); date of birth; amount charged and the tariff code where applicable.
  • Stale period-only claims received within 4 months of treatment will be paid.

Tips for claiming

  • Check the prescriptions for medicine show all your details. If the pharmacy or doctor omits any of these details, Swazimed is unable to process your claim and this may lead to delays.
  • Dental treatment often requires additional work by a dental technician. The technician then bills the dentist who adds this to your account and attaches a copy of the technician’s account. Please submit both accounts and ensure that your name and number are reflected on both.

Important

  • Group members are allowed to terminate membership only if the employer decided to withdraw all her employees from the fund within a 3 months notice. Termination is only allowed at the end of December. Individuals are not allowed to withdraw voluntarily.
  • Group terminations before December will pay contributions for the remaining period until December.
  • For treatment/coverage abroad, members are advised to take a separate cover.

When can I expect payment?

Swazimed has regular payment cycles of two weekly payments runs per month to members and suppliers. All valid claims received by Swazimed will be processed on this basis.

How will I know what was paid?

A claims Transaction Statement will be sent to you if Swazimed has processed an account during that month. This statement will indicate all payments made to you on your behalf.

What will the fund not pay for?

  • Costs above Scale of Benefits, or above your annual or category limits.
  • Treatment for obesity and artificial insemination.
  • Cosmetic surgery which includes plastic and reconstructive surgery, breasts reductions or enlargements, removal of excess fat and skin grafts.
  • Self-inflicted injuries.
  • Injuries arising from professional sport or speed contests.
  • Conditions which were specifically excluded when you joined the fund.
  • Items which can be purchased from supermarkets i.e. shampoo.
  • More than one months’ supply of medication.
  • Vitamin supplements unless younger than 2 or older than 65 years.
  • Immunisations.
  • Injury on duty which is paid by Worksman’s Compensation.
  • Heart operation, renal failure, oncology, organ transplant within first 8 months of joining the fund.
  • Any conditions existing before or during waiting period.
  • Optical benefits within first 12 months of joining the fund.

Important

Contact your Swazimed offices before undergoing any treatment. Should you sustain injuries as a result of an accident, an assault or an injury on duty, please contact your Swazimed offices to discuss what you should do.

A detailed list of the benefits excluded can be obtained from the Swazimed membership department.