Claims

Settling of Claims

A member should ensure that healthcare providers charge fees in accordance with the Scheme rates.

Some healthcare providers submit their claims directly to the Scheme, while others prefer the patient to pay them directly after the consultation or treatment. If payment has been made by the patient, the Scheme shall reimburse the member based on the acceptance of the claim.

Claims are assessed for validity using benefit rules. If the claim is valid and the benefits are not depleted, the amount is reimbursed directly to the member's bank account. This assessment takes place twice a month; once the assessment is completed, a claims statement is generated and sent to the member either via post or email.

  • 1
    Check for the following information on your doctor's account/invoice.

    Required information

    The Scheme's registered name The main member and the patient treated The membership number The doctor's practice number ICD-10 codes Signed proof of payment
  • 2
    gestureSign and date the claim and sign the proof of payment.
  • 3
    Email

    Scan or photograph each page, make sure that the quality is good.

    Attach and email to us, email each page separately - no zip files or multiple attachments will be accepted.

    OR
    Post

    Place in an envelope and post to us:

    PG Group Medical Scheme
    PO Box 2070
    Bellville
    7535
  • 4
    printKeep a copy of the claim
  • 5
    Upon processing claims, a statement will be generated and sent via email or post. Approved claims will be paid within 30 days of receipt.
  • 6
    Costs are reimbursed to your bank account upon claims processing.

Accidents and injuries

Accidents and injuries resulting from motor vehicle accidents will be reimbursed at 100% of cost if PMB-related, even if you are involved as a third party, e.g. a pedestrian. Members are required to submit claims to the Road Accident Fund. Any amounts recovered for medical expenses already paid by the Scheme, are immediately refundable to the Scheme.

  • The following documents should be submitted for your claim to be considered:
  • An accident injury report
  • A police/accident report
  • A signed legal undertaking

Reports on injuries

Even if you suffer a minor injury, you will be required to submit a report/letter from your healthcare provider detailing the cause of the injury. Where the injury is severe, you will be required to complete and submit an accident/injury report before any claims will be considered for payment.

Please contact 0860 00 50 37.