TABLE OF CONTENTS


It is important to remember the Sirago definition of family and dependants, and how Sirago applies the various rules and scenario’s related to these. The Sirago policy covers the policyholder and dependants who are listed on the Schedule of Insurance.


Definitions:


  • Policy holder: If you own an insurance contract or policy, you are a policyholder, also known as the policy owner. As a policyholder, you may also be the person covered by the policy.
  • Beneficiary: A person(s) other than the policyholder of an insurance policy who is entitled to receive benefits. This includes a 'child dependant', 'student' and an 'adult dependant' 
  • Dependant: Someone who is dependent upon the policy owner for access to the benefits available within this policy. This includes an 'adult dependant'
  • Family: This is defined as a group consisting of related adults and child dependants listed on your medical scheme option
  • Child: A child is considered as a child dependant up to the age of 21 (twenty-one). This includes a natural child, stepchild, or a legally adopted child
  • Scholar: An insured that is attending primary or secondary school. This definition specifically excludes any student or attendant of a tertiary institution
  • Student: A child aged 21 (twenty-one) to the age of 27 (twenty-seven) who is a full-time student at a registered institution and is still financially dependent on the policy holder 
  • Certificate of Membership (COM): An official document issued by your medical scheme or Gap Cover Provider indicating all relevant beneficiaries, waiting periods and/or contributions/premiums applicable to the medical scheme/policy.


Family Size Rules:


We cover you, your spouse/live-in partner, and all dependants on one policy, if you belong to a single medical scheme option.


For families who belong to a single medical scheme or medical scheme option, we cover all beneficiaries of all ages as listed by the medical scheme, or on the option.


We cover you and your spouse/live-in partner on one policy if you belong to different medical schemes, or medical scheme options, and this cover includes all child dependants registered on your or your spouse’s medical scheme option. This is limited to a maximum of 2 adults only in this category of membership.


A child is considered as a child dependant up to the age of 21 (twenty-one), this cover can however be extended to the age of 27 (twenty-seven) if they are full-time students and are still financially reliant on you. Documented proof of full-time studies is required to verify dependants over the age of 21(twenty-one). A child dependant can include your natural child, your stepchild, or a child you have legally adopted.


Child dependants that meet the definition of full-time students, who are principal members of their own medical scheme option, will be deemed as child dependants on their parents’ Sirago policy.



Examples:


Example 1: Multiple Medical Scheme Memberships - 1 Adult, Multiple Children.

  • Medical Scheme A = Policyholder and three dependants under the age of 21.
  • Medical Scheme B = Spouse, two dependants under the age of 21 and one student aged between 22 and 27.


For different Medical Schemes we cover 2 adults and all child dependants. All dependants from Medical Scheme A and Medical Scheme B can be covered on one policy.



Example 2: Multiple Medical Scheme Memberships - Multiple Adults and Dependants.

  • Medical Scheme A = Policyholder, parent and two dependants under age of 21.
  • Medical Scheme B = Spouse and student aged between 22 and 27.


For different medical Schemes we cover 2 adults and all child dependants. Policyholder, spouse, child dependants from Scheme A and student from Scheme B can be covered on one policy. 


Parent from Scheme A cannot be covered on the same policy as we only allow two adults if on multiple Memberships.


Example 3: Multiple Medical Scheme Memberships -Multiple adults and Student Dependant.

  • Medical Scheme A = Policyholder.
  • Medical Scheme B = Spouse with two dependants under age of 21.
  • Medical Scheme C = Student aged between 22 and 27.


For different medical Schemes we cover 2 adults and all child dependants. All dependants from Medical Scheme A , Medical Scheme B and Medical Scheme C can be covered on one policy.


Please note the student dependant from Medical Scheme C is deemed to be a child and can be covered without violating the two adults per policy if multiple Memberships rule.


Supporting Documentation Required:


Sirago reserves the right to call upon supporting documentation such as proof of enrolment or a recent copy, not older than 30 days of the medical scheme certificate of membership.

  • Certificate of Membership (COM): A copy of the medical aid certificate of membership that is not older than 30 days
  • Proof required for students:  A copy of the current student registration document at a registered tertiary institution to verify the dependants’ student status. Please note that a student card or an invoice of fees is not accepted.
  • Proof required for students who are principal members of their own medical scheme option: A copy of the current student registration document at a registered tertiary institution and a copy of the medical aid certificate.


In the event that the dependant is not a student and not a principal member of their own medical scheme option, should we receive a claim for this beneficiary, Sirago will initiate the required investigations in order to authenticate the validity of the beneficiary in direct relation to the prescribed policy wording which could delay the payment of the claim, or may even result  in the full repudiation of the claim, should the beneficiary status fall outside of the policy rules.