Claims

When you are sick or injured and unable to perform any of your usual occupational duties due to that sickness or injury:

The S&PI product has two waiting periods, namely, seven or thirty days. Thus, depending on the waiting period you have chosen, the benefit will be paid as follows:

• Seven-day waiting period: A Total Sick Pay benefit will be considered if you were totally unable to perform any of your usual professional duties for at least seven consecutive days, due to sickness and will pay from day one retrospectively. Once this initial requirement for a minimum period of seven consecutive days of total incapacity is met, for the same or related condition, ongoing claims can be submitted for continuing total or partial claims. A partial claim is where if, after a valid total Sickness claim, the member can perform some of their usual professional duties but are still unable to carry out normal duties or work normal hours, PPS will pay the member a partial Sickness benefit (50%).
• 30-day waiting period: A Sick Pay benefit will be considered if you are unable, either totally or partially, to carry out your usual professional duties for at least 30 consecutive days due to sickness. The Sick Pay benefit will be paid on either a Total or a Partial basis, whichever is applicable, prospectively from day 31. 

Please refer to your policy certificate to confirm if you have a seven or 30-day waiting period.

No, to claim the Admission Rider benefit you only have to be in hospital for four consecutive days (three consecutive nights) or more.

• A claim form completed by you (Declaration by Member form)
• A claim form completed by your treating doctor (Declaration by Doctor form)
• Proof of hospitalisation showing admission and discharge dates (front page of account or discharge form) for the Admission Rider and/or Family Responsibility Rider benefits.
• A marriage certificate, an unabridged birth certificate of the child and proof of medical aid for claims relating to your spouse or child.
• A copy of the official adoption court order and/or official proof of the registration of the adoption with the Registrar of Adoptions, a copy of the marriage certificate pertaining to the spouse and proof of medical aid for an adopted child.
• The respective benefit claim forms, completed by the member and the treating medical doctor, along with the unabridged birth certificate or proof of adoption papers, marriage certificate and death certificate (where applicable), for the Child Terminal Illness benefit.

To enable PPS to manage claims and ensure that all valid claims are paid, the standard recovery times provide a guideline to assessors of what is considered a reasonable period to recover from a specific illness or procedure. The concept of "standard recovery time" considers current clinical practice and relevant medical literature in conjunction with PPS's claims experience. PPS will approve the sick-pay period, which aligns with current clinical practice.

If your claim period extends beyond the expected recovery time, PPS will request additional medical information from your treating doctor or specialist. This helps us understand why the recovery is taking longer. Based on the doctor’s clinical findings, we will assess how the illness continues to affect your ability to perform your usual professional duties and make an informed decision on the extended claim period.
Should the treating specialist/doctor have extended this period, the doctor will be asked to provide additional supporting information based on their medical examination. Based on this additional supporting information, PPS will be able to make an informed decision on the remainder of the claim period, considering the illness and its effect on your ability to perform your nominated profession.

Additional medical information may be required to determine the progression of the medical condition, whether there are any complications with treatment and the prognosis. A general medical history questionnaire may also be requested. This could include an independent medical evaluation by a specialist chosen by PPS or an occupational therapy evaluation.

• There is a special claims protocol in place for the following conditions:
• Chronic pain.
• Chronic fatigue, tiredness or fatigue.
• Any psychiatric syndromes.
• Any cognitive impairment.
• Any inflammatory conditions of soft tissue.
• Vertigo, dizziness, loss of balance or tinnitus.
• Conditions that may have started prior to the business being granted, which could become chronic conditions or are already classified as such.

For claims related to these conditions, the assessor may ask for:

• Copies of clinical notes from the treating or usual doctor or the doctor who completed the medical reports at the time of application for the policy.
• The Mental and Behavioural Questionnaire (for psychiatric claims) completed by the doctor who booked the member off.
• A Medical History Questionnaire from the doctor who booked the member off for the following conditions:
  a) Fibromyalgia, chronic fatigue syndrome (CFS), myalgic encephalomyelitis (ME) or post-viral fatigue.
  b) Any condition related to CFS, connective tissue disorders, autoimmune diseases or ME.
• The General Claims Questionnaire completed by the member.
• Additional information directly from the member or their treating doctor to support and finalise the claim.
• A consultation with a medical specialist in the relevant field, as requested by the assessor, to support the claim.

For any further questions about these conditions or the claims process, members are encouraged to refer to their policy documents or speak to their PPS-accredited financial adviser.

F​ully completed claim forms must be sent to [email protected].

The entire process should not take more than eight working days to finalise.

​The process will take longer if additional information is required or if the standard forms have not been completed correctly. Submitting incomplete forms will lead to delays.

No, there is no limit to the number of claims you can submit. However, if your claims are for the same or similar condition, or one related to an existing condition, the total claim period is limited to 728 days. At the end of the 728 days, the member will be assessed for Permanent Incapacity benefits.

Your benefit will depend on the sickness cover amount reflected on your remittance advice and will be calculated based on the number of days of sickness.

If you elected to have the Admission Rider benefit, you will be paid an additional benefit calculated based on the number of days in hospital, multiplied by the cover amount for Admission benefits.

• District, regional and provincial hospitals
• Private hospitals
• Spinal rehab units
• Infectious diseases hospitals
• Rehab step-down facilities (e.g., Life Rehab)
• Step-down Institutions
• Frail care facilities

Which hospitals are not covered?

• Alcohol and substance abuse rehabilitation centres.

• If you have the Family Responsibility Rider benefit, effective BEFORE 1 April 2017, you will be paid a benefit if your spouse or child is hospitalised for four consecutive days (including three overnight stays) or more.
• If you have the Family Responsibility benefit, effective AFTER 1 April 2017, you will receive a benefit if your spouse or child is hospitalised for at least three consecutive days (including two overnight stays).

Partial sickness refers to situations where, due to illness, you are unable to complete all your regular work tasks or fulfil your usual hours. However, you are still able to perform some of your standard duties. You may be eligible for a Partial Sick Pay benefit in such cases, after first claiming for total illness (on the seven-day waiting period). This requires that you spend part of each workday on tasks related to your normal occupation, using your established professional skills and knowledge. You must notify PPS of this change before you begin performing duties outside your usual role.
If you work on a partial basis, you can submit a claim for partial sickness, which is paid at 50% of your sickness benefit.
After a period of 728 days for the same or related condition, if you are still unable to perform your usual professional duties, you may be assessed for a Permanent Incapacity benefit. 
If you have claimed partial incapacity for 728 days for the same or a related illness and are still unable to do your usual work, you may be considered for a Permanent Incapacity benefit.
This is based on the impact of an impairment on the ability to perform usual professional duties until the chosen benefit cease date is reached or until the member recovers. The award can be either 20%, 60% or 100%. 

Usual professional duties are those occupational tasks which you carry out as part of your occupation prior to claim. This includes administrative duties such as sending e-mails and making telephone calls related to your business or occupation.  

The Sick Pay Benefit calculation differs depending on whether the graduate professional is salaried or self-employed.
For salaried graduate professionals, the benefit will be limited to the greater of:

• Two-thirds of gross personal income; or
• Net of tax personal income.

For self-employed graduate professionals, the benefit will be limited to the greater of:

• Two-thirds of gross personal income plus 100% of actual business expenses prior to the claim; or
• Net of tax personal income plus 100% of actual business expenses prior to the claim.
   

If a claim extends over several months, PPS requires the following:

• A Declaration by Member (DBM) and Declaration by Doctor (DBD) form must be submitted monthly by the 25th of the month being claimed for.
• Confirmation that the member consulted their doctor in person during each month of the claim period.

Please note the following:

• Claims must be submitted monthly. Delays in submission will result in delays in the payment of benefits, as the claims management team is required to assess long-term claims regularly.
• PPS does not accept forms completed following telephonic consultations.
• The Declaration by Doctor form must be completed by a treating specialist who is appropriately qualified in the field of medicine relevant to the condition.

In some cases, such as recovery following surgery, the treating specialist may book the member off for an extended period. In these instances, the member may only be required to submit the DBM monthly. This will be determined by PPS assessors at the time of claim assessment.

Additional requirements may include:

• Progress reports or questionnaires from the attending specialist (at PPS’s cost).
• Questionnaires completed by the member to assess the impact of the condition on daily activities and professional duties.
  Independent assessments arranged by PPS (at PPS’s cost).

Yes, your claim may include public holidays and weekends.