Medical aid claim submission letter template

Use it for a claim you paid yourself and want refunded, for a paper account the provider gave you, or for a claim that seems to have been lost. If the scheme has already rejected a claim, use the appeal letter instead. The how to claim guide covers claiming through the app or portal.

We found no national claims deadline in the sources we checked, so read your scheme's rules or ask. Submit as soon as you have the account, and do not wait to collect every document.

[Your full name]
[ID number]
[Membership number]
[Cellphone] | [Email]
[Date]

To: The Claims Department
[Scheme name]

Subject: Claim submission - membership number [MEMBERSHIP NUMBER]

Dear Sir or Madam

Please process the attached claim.

Patient: [NAME AND DEPENDANT CODE]
Date of service: [DATE]
Provider: [DOCTOR OR PRACTICE NAME AND PRACTICE NUMBER]
Amount claimed: R[AMOUNT]

I attach:
1. The detailed account, showing the practice number, ICD-10 code(s) and tariff or procedure code(s).
2. Proof that I paid the account.
3. [REFERRAL, SCRIPT OR AUTHORISATION NUMBER, IF THERE IS ONE].

I paid this account myself, so please refund the amount you approve to:
Bank: [BANK]
Account holder: [NAME]
Account number: [ACCOUNT NUMBER]
Branch code: [BRANCH CODE]

Please confirm receipt and give me a claim reference number. If any part is not paid, please send me the reason in writing.

Yours faithfully
[Full name]
[Signature]

A card slip or till slip proves you paid, but it does not prove what the treatment was. Ask the provider for a detailed account or invoice that shows:

• the provider's name and practice number;
• the patient's name and the date of service;
• the ICD-10 diagnosis code or codes;
• the tariff or procedure codes, with an amount for each;
• for medicine, the item code and quantity, where the pharmacy gives them.

The diagnosis code matters because PMBs are diagnosis-based. A wrong code can make a claim look like an ordinary benefit instead of a prescribed minimum benefit.

• The detailed account, not a photo of a quote.
• Proof of payment, such as an EFT confirmation or a receipt stamped paid.
• The referral, script or authorisation number where one applies.
• Your bank details for the refund, in the letter.

Put your membership number and the patient's name on each page, so a loose page cannot be lost.

Email the letter and attachments to the claims address on your scheme's website, or upload them through the member portal or app. Save the sent email, or a screenshot of the confirmation screen, and note the reference number. If you post it, use registered post and keep the slip.

Keep the original account. Send copies, not the only one you hold.

A refund is not always the full amount on the account. The usual reasons are that the scheme pays at its own rate, a benefit limit or savings balance is used up, or a co-payment applies. Choosing a non-DSP provider voluntarily can also bring a co-payment. See co-payments and sub-limits.

The exception is a PMB. Every benefit option must pay PMB diagnosis, treatment and care costs in full, without a co-payment or deductible, though the scheme can require its DSP and protocols.

Gap cover is an insurance product, not a medical scheme, and it is claimed from the insurer. Its yearly benefit limit from 1 April 2026 is R226 881.03 per insured person. Keep the scheme's payment statement, because the insurer will ask for it. See gap cover explained.

We found no national timeline for the scheme to pay, so ask for a reply date and follow up in writing with your reference number. If the claim is rejected, ask for the reason in writing. Many rejections are fixed with a corrected code or a missing document. If you cannot resolve it, use the complaint letter, which ends with the Council for Medical Schemes.

Common mistakes:

• Sending a card slip instead of the detailed account.
• Not checking your scheme's claim deadline.
• Leaving out your bank details, or the patient's dependant code.
• Sending the only copy of the account.
• Not keeping a reference number.