Order

DECLARATION BY APPLICANT

Standard Declaration

I warrant that the information provided to the insurer in connection with the policy, whether in my own handwriting or not, is true and correct.

I, the undersigned, hereby declare that:

1. All the information that I give, whether telephonic, electronic or written, will form part of the policy.
2. To the best of my knowledge and belief the information provided in connection with this application, is true and I have not withheld any material facts known to me.
3. I understand that this is an accident and health policy with stated benefits in terms of the Short-term Insurance Act 53 of 1998. This is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership.
4. I acknowledge that the sharing of claims information and underwriting (including credit information) by insurers is essential to enable the insurance industry to underwrite policies and assess risk fairly and reduce the incidence of fraudulent claims, in the public interest and with a view to limiting premiums. I hereby waive any rights to privacy of any claim information supplied by me or on my behalf in respect of any insurance claim made or lodged by me and I consent to such information being disclosed to any other insurance company or its agent. I also waive any rights to privacy and consent to the disclosure of any information relevant to claims concerning me or any person I represent. I also acknowledge that information provided by me may be verified against other legitimate sources or databases.
5. If the insurer accepts this application, it will be on condition that there is no important change to the facts that I disclosed and upon which this application is based and accepted. If there has been such a change, I must inform the insurer within 30 days of the occurrence in order for him to reassess the risk for the insurance cover.
6. I acknowledge and appoint Optivest Health Services (FSP no. 13475) as intermediary to provide ongoing intermediary services to me regarding this policy. I agree that the insurer may pay commission to the intermediary in terms of the Short-term Insurance Act 53 of 1998.
7. Upon receipt of my policy document, I will familiarise myself with all the terms and conditions of the policy and contact my Intermediary or the Administrator for clarification should anything be unclear.
8. This consent is to remain in force after my death OR until I specifically request to end the consent, which will be required in writing.

IMPORTANT TERMS AND CONDITIONS OF THIS POLICY

I understand and agree that:

1. To qualify for benefits under this policy, I must be a member, and my insured family must be dependants of a medical scheme approved in terms of the Medical Schemes Act and my dependants must be registered as dependents on the policy.
2. Cover will commence on the 1st day of the calendar month for which the insurer accepts my application for insurance and receives my first premium.
3. The Policy Premium may be changed annually, after the insurer has given me 30 days’ notice. If I do not pay my premiums in full, I will not be covered.
4. In terms of the policy, the insurer will pay the difference between the surgical and consultation fees charged by health professionals for insured events and the benefits payable by my medical scheme. Terms and conditions will apply as stipulated in the policy contract.
5. A maximum benefit of R177 835.05 will be payable per beneficiary per policy per annum. A sub limit of R16 500 per event is applicable to all CoPay Cover claims and Non-DSP hospital co-payments are limited to one event per policy per annum.
6. Termination of cover will take place if I have given a calendar month’s written notice of cancellation, if 3 consecutive premiums are unpaid, or if a dependant does not qualify for cover on my policy.
7. Benefits will not be paid:
• If the medical scheme pays the entire claim or pays short due to scheme limits or exclusions.
• If I do not submit my claim within 4 months of the date of payment by my medical scheme.
• For the first 3 months of cover. (Please refer to full definition and details supplied on the Policy Contract)
• For the first 12 months of cover in respect of any pre-existing condition. (Please refer to full definition and details supplied on the Policy Wording)
8. This policy does not cover Prescribed Minimum Benefits (PMB) as defined in the Medical Schemes Act 131 of 1998 with Regulations, which are payable by my medical scheme.
9. The full terms and conditions are provided in the Policy Contract.