Claims

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

The SPPI product has two waiting periods, namely, seven (7) days or thirty (30) days. Thus, depending on the waiting period you have chosen, the benefit will pay 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. Once this initial requirement for a minimum period of seven consecutive days of total incapacity is met, on-going claims can be submitted for continuing total or partial claims.
• 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-day or 30-day waiting period.

No, to claim the Admisssion Rider benefit you only have to be in hospital for four consecutive days (3 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)

For Admission benefits we require proof of hospitalisation showing admission and discharge dates (front page of account or discharge form).

For claims relating to your spouse or child, we require a marriage certificate, unabridged birth certificate of the child and proof of medical aid.

For adopted children we require 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 the child.

For the Child Terminal Illness and Death benefit, we require the respective benefit claim forms completed by the member and treating Medical Doctor, the unabridged birth certificate or proof of adoption papers, marriage certificate and a death certificate where applicable.

To enable PPS to manage claims and to 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 is in line with this current clinical practice.

Should this period have been extended by the treating specialist/ doctor, the doctor will be asked to provide additional supporting information based on his/her 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 effect thereof on your ability to perform your nominated profession.​

The assessor may request additional information to determine when your illness started and to get a history of your illness. We may also require a general medical history questionnaire. There may be other reasons why the assessor may call for additional information, for example, to determine the effect the condition has on your ability to attend to your activities of daily living and how the sickness affects your ability to do your work. This could include an Independent Medical Evaluation by a Specialist chosen by PPS or an Occupational Therapy Evaluation.

Special protocol for certain medical conditions:

Mental and Behavioural disorders, fibromyalgia, chronic fatigue syndrome, on-going chronic auto-immune and connective tissue disorders, back conditions,conditions that may have started prior to the business being granted, that could become chronic conditions or are already classified as chronic conditions.

Assessor may ask for:

1. Copies of clinical notes from your treating doctor, or usual doctor or the doctor who completed the medical reports at application for the policy. 
2. ​Mental and behavioural questionnaire from the doctor who booked you off – Psychiatric claims.
3. ​​Medical History Questionnaire from the doctor who booked you off (fibromyalgia/chronic Fatigue Syndrome/ME/Post Viral Fatigue) - Any chronic fatigue/myalgicencephalitis/connective tissue/auto immune claims.
4. ​General claims Questionnaire completed by yourself.​
5. ​The assessor may verify your medical aid records or any other information pertinent to the medical history of your condition. In order to finalize the claim the assessor may request further information directly from members or their treating doctors.
6. ​You may be asked to consult a medical specialist who is an expert in that particular field of medicine relating to your claim.

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

The entire process should not take more than 8 working days to finalise.

​The process will take longer if additional information is required or if the standard forms have not been completed correctly. If the forms have been incompletely filled in  by either yourself or your doctor, this will lead to delays

No, there is no limit to the number of claims you can submit. However, claims for a condition that is regarded as the same or similar or as a result of an existing condition or related to an existing condition, will be limited to 728 days.

Your benefit will depend on the sickness cover amount reflected on your Statement of Benefits 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 that will be 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 rehabilition centres.

If you have elected to have the Family Responsibility Benefit, and the benefit was effective before 01 April 2017, you will be paid a benefit if your spouse or child is hospitalised for four consecutive days (three nights) or more.

If you have elected to have the Family Responsibility Benefit, and the benefit was effective after 01 April 2017, you will be paid a benefit if your spouse or child is hospitalised for three consecutive days (two nights) or more.

You may qualify for a Partial Sick Pay Benefit if you are not able to carry out all your normal duties or normal work hours, due to the sickness, but you are able to attend to some of your usual professional duties. ‘Some of your usual professional duties’ means that you have spent time during the working day attending to some of your duties and applying your knowledge and skill related to your nominated occupation. Should you be able to attend to duties related to a different occupation, you must advise PPS of such change of occupation. 

You may submit a claim for being able to work on a partial basis which will be considered and paid at a partial benefit rate. Calculations will depend on the benefits held.

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.  

GPI is personal income and actual expenses derived before tax. As per the terms of the Provider Policy, a member cannot receive sick pay benefits in excess of two-thirds of his/her GPI or total cost to company salary at time of claim. Thus, PPS can perform a financial review when a sick-pay benefit claim has been submitted to determine whether a member has the appropriate amount of cover. 

PPS will require:

​Monthly claim forms will be required, a Declaration by Member from you and a Declaration by Doctor from your doctor.

​​You will be required to consult your doctor monthly.

​If claims are not submitted regularly on a monthly basis there will be delays in the future payment of benefits.  The claims management team are required to request information regularly for long term claimants, and if they are not able to do this there will be delays in the assessment of your claim.

​Completion of forms based on Telephonic consultations are not accepted by PPS.

​​Fully completed and signed claim forms (Declaration by Member and Declaration by Doctor Forms) should be submitted to PPS on the 25th of the month you are claiming for.

​The Doctor’s Declaration form must be ​completed by your treating appropriate or relevant Specialist, that is, a doctor who has specialised in the field of medicine related to your condition. 

​Additional requirements will be communicated to you and may include:

​Progress reports/questionnaires from your attending specialist (at PPS’s cost).

Questionnaires to be completed by you (to determine the effect the condition has on your daily activities of living and your ability to perform your usual professional duties).

​You may be required to go for an independent assessment at PPS’s cost.

Yes, your claim may include public holidays and weekends.