Claims | X Underwriting

The process

How to Submit a Claim

Register your claim online through our claims portal, or ask your accredited broker to submit on your behalf through Xcelerate.

STEP 01

Receive Treatment

Undergo your in-hospital procedure, specialist visit, or covered treatment. Your medical scheme will process their portion and issue a medical scheme statement.

STEP 02

Gather Your Documents

Collect your medical scheme statement, the service provider's invoice, and any relevant medical reports. Supplementary documents may be required depending on the claim type. See the checklist below.

STEP 03

Submit Your Claim

Register your claim through our online claims portal, or ask your broker to submit on your behalf through Xcelerate. Claims are acknowledged within 1 business day of receipt.

STEP 04

Receive Your Payment

Once assessed and approved, payment is made directly to you, subject to policy limits. Most claims are processed within 5 to 10 business days of receiving all required documents.

Required documentation

What You Will Need

Ensure you have all of the following ready before submitting your claim. Incomplete submissions may result in delays whilst we await outstanding documentation.

Core documents

✓
Medical Scheme Statement The statement from your medical scheme confirming what they paid and what shortfall remains. Request this directly from your scheme after treatment.
✓
Service Provider Invoice The original invoice from your doctor, casualty unit, or hospital, itemised with procedure codes, amounts charged, and provider details.
✓
Medical Reports Relevant clinical documentation supporting the claim, such as a histology report, casualty report, or specialist's notes, depending on the nature of the treatment.

Supplementary documents (where applicable)

+
Monthly Medical Scheme Membership Certificate Required to confirm active membership at the time of the event. Request this from your medical scheme.
+
Death Certificate Required for claims relating to accidental death, premium waiver, or medical scheme premium cover benefits.
+
Police Report Required for accidental death or trauma-related claims where the event involves a criminal act, accident, or hijacking.
+
Permanent Disability Report A medical assessment confirming the nature and permanence of the disability, required for disability-related benefit claims.
+
Proof of Co-Payment Documentation confirming the co-payment or excess charged by your medical scheme, such as a scheme notice or provider receipt.

Important

Claims must be submitted within 90 days of payment by your medical scheme. Late submissions may not be accepted. Please contact our claims team in advance if you have exceptional circumstances.

Common questions

Claims FAQ

Answers to the most frequently asked questions about submitting and tracking X Gap Cover claims.

How long does a claim take to process?

Most claims are processed within 5 to 10 business days from the date we receive all required documentation. Incomplete submissions may take longer, as we will contact you to request the outstanding documents.

What is a medical scheme statement?

A medical scheme statement (sometimes called a Claims Transaction History) is a document from your medical aid detailing your treatment claim, including what was charged, what the scheme paid at their rate, and what shortfall, if any, remains. You can request this from your medical scheme directly after receiving treatment.

Can I claim for out-of-hospital treatment?

Yes, depending on your plan. Emergency room visits are covered on all four plans. Apex covers specialist consultations (R6 000 per policy per year, up to 4 claims of R1 500), primary care consultations (R2 000 per policy per year, up to 4 claims of R500) and preventative care (R3 000 per policy per year, up to 2 claims of R1 500). Nexus 2 covers the same three per insured person: specialist consultations (R2 000 per year, up to 2 claims of R1 000), primary care (R1 000 per year, up to 2 claims of R500) and preventative care (1 claim of up to R1 500 a year). Nexus 1 covers preventative care (1 claim of up to R1 000 a year) but not consultations. Appliance shortfalls are covered on Nexus 2 and Apex, and trauma counselling on Nexus 1, Nexus 2 and Apex. Vertex does not cover consultations or preventative care, but it does cover emergency room visits and its cancer benefits.

Is there a time limit for submitting a claim?

Claims must be submitted within 90 days of payment by your medical aid. We encourage you to submit as soon as you have your medical scheme statement, service provider invoice, and any required medical reports. If you have exceptional circumstances, please contact our claims team before the deadline expires.

Can my broker submit a claim on my behalf?

Yes. Your accredited X Gap Cover broker can submit and track claims on your behalf through the Xcelerate administration platform. Many of our members prefer this route, as brokers are experienced in claims processing and can ensure all documentation is in order before submission.

What if my claim is declined?

If your claim is declined, in full or in part, we will tell you in writing and explain why.

You have 90 days from the date of our decision to ask us to reconsider it. Please send your written representations to complaints@x-underwriting.co.za, setting out why you disagree and attaching any supporting documents. We will respond in writing within 31 days of receiving them.

If you remain dissatisfied, you may refer the matter to the National Financial Ombud Scheme at no cost to you. You also have a further six months, after the 90 day period, to institute legal action.

Please note that if you do not act within these timeframes, your claim will be regarded as prescribed and abandoned, and can no longer be pursued.

You may also follow our Claims Complaints Procedure, available on the Documents page.

Where is payment made, to me or to the provider?

Payment is made to you as the policyholder, not directly to the provider. You may then use the funds to settle any outstanding amounts owed to your doctor, specialist, or hospital. Your banking details are required for all first-time claims.

Simple, Straightforward Claims

How to Submit a Claim

Receive Treatment

Gather Your Documents

Submit Your Claim

Receive Your Payment

What You Will Need

Submit Your Claim

Claims Registration Portal

Claims FAQ

Still Have Questions?
We Are Here to Help

Simple, Straightforward Claims

How to Submit a Claim

Receive Treatment

Gather Your Documents

Submit Your Claim

Receive Your Payment

What You Will Need

Submit Your Claim

Claims Registration Portal

Claims FAQ

Still Have Questions?We Are Here to Help

Still Have Questions?
We Are Here to Help